Foundations Exam 3
A client has come to the emergency department with a new onset of chest pain rated at 7 on a 0-10 scale. Which laboratory test does the nurse anticipate will be ordered? A.CK B.HDL C.WBC D.Troponin
A
The nurse is assessing a client who had a coronary artery bypass graft yesterday. Which assessment finding indicates the client is at risk for decreased perfusion? ·A. Heart rate of 50 beats/min ·B. Potassium level of 4.2 mEq/L ·C. Systolic blood pressure of 120 mm/Hg ·D. 50 mL of bloody drainage in chest tube over 4 hours
A
The nurse is assessing the client's heart sounds. Which instruction will the nurse provide if there is difficulty in hearing heart sounds? A. "Please roll onto your left side." B. "Lay all the way down on your back." C. "Please hold your breath while I use my stethoscope." D. "I will just take your pulse instead."
A
The nurse is preparing to discharge a client who recently experienced a STEMI. Which client statement indicates understanding of nitroglycerin use? A. "The nitroglycerin should tingle when I put it in my mouth." B. "I will keep nitroglycerin in the glove compartment of my car." C. "Since the pills are small, they won't be hard to swallow." D. "The nitroglycerin should relieve the pain immediately."
A
What teaching will the nurse provide to a client who says, "Smoking doesn't hurt my heart"? A."Smoking increases risks for heart disease." B."Lungs are the only organ damaged by smoking." C."The impact of smoking is only on the heart." D."Are you worried about smoking?"
A
When answering the call light for a client on bedrest, the nurse finds the client's visitor unconscious on the floor with no discernable pulse and not breathing. The nurse estimates that at least 2 minutes have passed since the client's light first came on. What is the nurse's priority action? ·A. Initiate CPR with chest compressions. ·B. Perform an abdominal thrust maneuver. ·C. Assess the visitor for the presence of a head injury. ·D. Ask the client what event led up to the visitor's fall.
A
When working on smoking cessation measures, which client statement demonstrates to the nurse that further teaching is needed?A. "I wish there was a drug that could help me stop smoking." B. "I am going to look for nicotine gum at the store." C. "Quitting is going to be hard but I am willing to try." D. "While I'm cutting down, I will smoke outside instead of in the house."
A
Which assessment finding in an adult client does the nurse identify as most closely associated with lung disease? A. Cough B. Dyspnea C. Chest pain D. Sputum production
A
Which assessment finding will the nurse anticipate in a client with severe atherosclerotic disease? ·A. Carotid artery bruit ·B. HDL 60 mg/dL ·C. Palpable peripheral pulses D. BP 120/58 mm Hg
A
Which precaution is a priority for the nurse to teach a client prescribed the gene therapy combination of ivacaftor/tezacaftor in order to prevent harm from this therapy? A. Examine your skin and the whites of your eyes daily for a yellow appearance. B. Apply ice to the injection site for 30 minutes after each dose to keep bleeding to a minimum. C. Wait at least 15 minutes after using other inhaled drugs before inhaling this drug combination. D. Go to your primary health care provider immediately if you develop a fever or other signs of infection.
A
Which statement about the genetics of cystic fibrosis is true? ·A. Recessive disorder affecting chloride transport ·B. Recessive disorder affecting alpha1-antitrypsin levels ·C. Dominant disorder inhibiting alveoli formation ·D. Dominant disorder increasing production of interleukin-5
A
Which statement made by a client prescribed oxygen therapy at home indicates to the nurse that more instruction is needed? A. "When I want to smoke, I will use the liquid oxygen reservoir instead of the compressed oxygen tank." B. "Using oxygen should help me have more breath and stamina when I eat, bathe, and take care of myself." C. "Even though they contain alcohol, I can still drink a glass of wine or can of beer while using oxygen." D. "If my shortness of breath becomes worse or if I have chest pain I will contact my primary health care provider immediately."
A
Which symptom or change in assessment of a client with four broken ribs on the right side indicates to the nurse the possibility of a tension pneumothorax? ·A. Distended neck veins ·B. Mediastinal shift toward the left side ·C. Right-sided pain on deep inhalation ·D. Right side of the chest more prominent than the left
A
While responding to questions in a health history, the client reports that he usually expectorates about 2 ounces of thin, clear, colorless sputum daily, usually on getting up in the morning. What is the nurse's best action related to this finding? A. Document the report as the only action. B. Arrange for the client to have tuberculosis testing. C. Collect a sputum specimen for laboratory analysis. D. Alert the primary health care provider about this funding.
A
The nurse teaching clients precautions to use with drug therapy for primary pulmonary arterial hypertension (PAH) instructs the female clients to use two reliable forms of contraception while taking which drugs? Select all that apply. A. ambrisentan B. bosentan C. epoprostenol D. iloprost E. macitentan F. riociguat G. selexipag H. sildenafil I. tadalafil J. treprostinil
A,B,E,F
Which condition, sign, or symptom does the nurse consider most relevant in assessing a client suspected to have ARDS? Select all that apply. ·A. Dyspnea ·B. Electrocardiogram shows ST elevation ·C. Intercostal retractions ·D. PaO 2 84% on oxygen at 6 L/min ·E. Substernal pain or rubbing ·F. Wheezing on exhalation
A,C,D
The nurse is caring for a client with chest pain. What assessment data would cause the nurse to suspect unstable angina? Select all that apply. ·A. ST changes ·B. Troponin T 0.6 ng/mL ·C. Pain lasts 15 to 25 minutes ·D. Increased number of angina attacks ·E. The intensity of the chest pain has increased
A,C,D,E
A client being mechanically ventilated has all of the following changes. Which changes are most relevant in helping the nurse determine whether suctioning is needed at this time? Select all that apply. A. Decreased SpO 2 B. Elevated temperature C. Crackles auscultated over the trachea D. Crackles auscultated in the lung periphery E. High-pressure ventilator alarm sounds F. Presence of fluid within the endotracheal tube G. Presence of fluid within the ventilator tubing
A,C,E,F
The nurse is teaching a class regarding reduction of risk factors for cardiovascular disease. Which teaching statement will the nurse include? Select all that apply. A. "If you tend to get angry easily, then your risk for heart disease is higher." B. "To reduce your overall risk, it is important to keep your BMI greater than 30." C. "Do not eat more calories on a daily basis that you are able to burn." D. "Decreasing the amount that you smoke will decrease your overall cardiovascular risk." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes."
A,C,E,F
The nurse is assessing an older adult client. Which assessment finding requires nursing intervention? Select all that apply. A. Tightening of vocal cords B. Increase in residual volume C. Feeling breathless during exercise D. Decrease in anteroposterior diameter E. Decrease in respiratory muscle strength
A,D
The nurse is admitting a client with an ulcer on the right foot. Which client statement indicates venous insufficiency to the nurse? Select all that apply. ·A. "My ankles swell up all the time." ·B. "My leg hurts after I walk about a block." ·C. "My feet are always really cold." ·D. "My veins really stick out in my legs." ·E. "My ankles have been discolored for years."
A,D,E
The nurse is providing community education regarding myocardial infarction. What teaching will the nurse include? Select all that apply. A. Denial is common reaction to chest pain. B. A myocardial infarction can occur in minutes. C. Exercise at least 20 minutes three to four times per week. D. Age is a significant risk factor in the development of CAD. E. Women are more likely to experience atypical chest pain. F. Atherosclerosis is a primary factor in the development of CAD.
A,D,E,F
The nurse is conducting an admission assessment on a male client. Which assessment data does the nurse identify as a risk factor for cardiovascular disease? Select all that apply. ·A. BMI of 26 ·B. BP of 120/66 mm Hg ·C. Triglycerides 140 mg/dL ·D. Moderate exercise for 20 to 30 minutes weekly ·E. Exposure to secondhand cigarette smoke ·F. History of repeated streptococcal tonsillitis ·G. Family history of cardiovascular disease
A,D,E,G
A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply. ·A. Blurry vision ·B. Constipation ·C. Difficulty sleeping ·D. Nausea when drinking beer ·E. Red-tinged urine ·F. Sunburn with minimal sun exposure ·G. Yellowing of the sclera
A,G
A client is admitted to the hospital with an abdominal aortic aneurysm. Which assessment data would cause the nurse to suspect that the aneurysm has ruptured? · A. Shortness of breath and hemoptysis · B. Sudden, severe low back pain and bruising along the flank · C. Gradually increasing substernal chest pain and diaphoresis · D. Rapid development of patchy blue mottling on feet and toes
B
A client newly diagnosed with stage I nonsmall cell lung cancer (NSCLC) who is getting ready for curative surgery asks the nurse whether the oncologist might consider this new drug he has seen on television, pembrolizumab, instead of surgery. What is the nurse's best response? A. "This drug will only work on those lung cancers that have the right target and your tumor does not have it." B. "This drug is approved for use in clients whose lung cancer has metastasized not for early-stage cancers." C. "Why would you want to take a drug for months when you may be cured by surgery alone?" D. "You need to talk about this with your oncologist and your surgeon
B
A client who 3 days ago underwent extensive abdominal surgery for cancer reports having a difficult time "catching her breath" and feeling very scared. After assessing the client, what is the nurse's best action or response to prevent harm? ·A. Ask the client about possible drug allergies ·B. Apply oxygen and initiate the Rapid Response Team ·C. Determine when she last received an opioid dose ·D. Check the oxygen saturation and encourage her to cough
B
A client who underwent radical neck surgery for head and neck cancer 5 days ago tells the nurse that he is worried because his right shoulder is lower than the left and does not go back into place when he tries to raise it. What is the nurse's best response? ·A. "I will notify the surgeon right away because some leftover tumor must be pressing on the nerve." ·B. "The nerve to the shoulder was removed during surgery. Physical therapy will help you to use other muscles to regain some motion." ·C. "This problem is not related to your surgery. If it persists after you go home you will need to see your primary health care provider about it." ·D. "Your time under anesthesia was long and you are not yet fully recovered. It is likely you will regain full motion in that shoulder by the end of the week."
B
A client with COPD has just been reclassified for disease severity from a GOLD 2 to a GOLD 3. Which client statement about changes in management or lifestyle indicate to the nurse that more teaching is needed to prevent harm? ·A. "This year I will get the pneumonia vaccination in addition to a flu shot." ·B. "Now I will try to rest as much as possible and avoid any unnecessary exercise." ·C. "Maybe drinking a supplement will help me retain weight and have more energy." ·D. "Perhaps using a spacer with my metered dose inhaler will make the drug work better."
B
A client with a history of chronic obstructive pulmonary disease is admitted with shortness of breath. Which nursing action is appropriate? A. Do not administer oxygen. B. Administer oxygen via Venturi mask. C. Use nasal cannula to administer high flow oxygen. D. Administer oxygen at 6L per simple face mask.
B
A client with hypertension asks about the cause. Which nursing response is appropriate? A."Pregnancy can cause essential hypertension." B."High cholesterol is a big factor in development of essential hypertension." C."Stopping caffeine intake can cause hypertension to go away." D.Race is associated with secondary hypertension.
B
A nurse assessing an older adult client with pneumonia notes the client is now confused and the oxygen saturation has dropped since the last assessment 1 hour ago from 90% to 84%. The nurse also notes the respiratory rate has increased from 26 to 32. What is the nurse's best first action? ·A. Encourage the client to use the incentive spirometer hourly. ·B. Increase her O2 flow rate by 2 L and reassess in 5 minutes. ·C. Increase the flow rate of the IV antibiotic. ·D. Document the changes as the only action.
B
A nurse interviewing an 82-year-old, somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an influenza vaccination today. The daughter replies "she had one 2 years ago and doesn't need another." What is the nurse's best response? A. "Your mother is older now and is more fragile, so she should have one this year, too, as a booster." B. "The virus causing influenza often changes each year, and a new influenza vaccination is needed every flu season." C. "The "flu shot" she had 2 years ago will still protect her this year, but if she has not had a previous pneumonia vaccination, she should have one now." D. "If you are worried that she is afraid to have an injection, we could use the nasal mist vaccination this year."
B
At the end of the visit, the primary health care provider prescribes hydrochlorothiazide 25 mg PO each morning. Which teaching will the nurse provide? A."This is a loop diuretic that decreases sodium reabsorption." B."Eat foods rich in potassium, such as bananas and orange juice." C."A potassium supplement will be prescribed along with this drug." D."This drug is a potassium-sparing diuretic that helps prevent the loss of essential potassium."
B
The client, who is 24 hours postoperative after a right lower lobectomy for stage II lung cancer and has two chest tubes in place, reports intense burning pain in his lower chest. On assessment, the nurse notes there is no bubbling on exhalation in the water seal chamber. What action will the nurse perform first? ·A. Immediately notify either the Rapid Response Team or the thoracic surgical resident. ·B. Assist the client to a side-lying position and reassess the water seal chamber for bubbling. ·C. Administer the prescribed opioid analgesic immediately, and then assess the chest tube system. ·D. No action is needed because these responses are normal for the first postoperative day after lobectomy.
B
The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding will cause the nurse to suspect cardiac tamponade? A. Incisional pain with decreased urine output B. Muffled heart sounds with the presence of JVD C. Sternal wound drainage with nausea D. Increased blood pressure and decreased heart rate
B
The nurse assessing an 88-year-old client notices a severe kyphosis that curves the client's spine to the right and bends her forward. Which change in respiratory function does the nurse expect as a result of this age-related change? ·A. Decreased gas exchange as a result of reduced airway elasticity ·B. Decreased gas exchange as a result of ineffective chest movement ·C. Reduced pulmonary perfusion as a result of decreased alveolar diffusion capacity ·D. Reduced pulmonary perfusion as a result of decreased blood return to the right atrium
B
The nurse is caring for a client immediately following a cardiac catheterization. Which assessment data require immediate nursing intervention? ·A. Blood pressure 146/70 mm Hg ·B. Hematoma developing at insertion site ·C. Client reports headache pain ·D. Client reports extreme thirst
B
The nurse is caring for a client receiving intravenous heparin for treatment of DVT who begins to begins to vomit blood. What action should the nurse be prepared to take? · A. Administer vitamin K · B. Stop the infusion of heparin · C. Administer an antiemetic · D. Insert a nasogastric tube
B
Which specific information will the nurse teach to the client with eosinophilic asthma newly prescribed benralizumab therapy? A. Avoid breathing into the inhaler or getting it wet. B. The drug can only be given by a health care professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because of the extreme drowsiness it causes
B
Which statement made by the client on the way to the catheterization laboratory requires an immediate action by the nurse? A. "My allergies are bothering me, so I took some Benadryl last night before bed." B. "I was nervous last night, but I still remembered to take my warfarin." C. "I sure am hungry. I haven't had anything to eat since I went to bed last night." D. "I don't know what I will do if they find a blockage in my heart."
B
While suctioning a client with a tracheostomy, the client becomes diaphoretic and nauseous and the heart rate decreases to 37 beats/min. What is the priority nursing action? A. Continue to clear the airway. B. Stop suctioning the patient. C. Administer atropine. D. Call the health care provider immediately.
B
Which conditions or changes indicate to the nurse that a client with a tracheostomy requires suctioning? Select all that apply. ·A. The client has a fever. ·B. Crackles and wheezes are heard on auscultation. ·C. The client requests that suctioning be performed. ·D. Suctioning was last performed more than 3 hours ago. ·E. The tracheostomy dressing has a moderate amount of serosanguineous drainage. ·F. The skin around the tracheostomy is puffy and makes a crunching sound when touched.
B,C
Which adults are at higher risk for development of active tuberculosis? Select all that apply. A. 21-year-old college student living in a dorm at a Canadian university B. 38-year-old with HIV-III (AIDS) who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years F. 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)
B,C,D,E
The nurse is caring for a female client with atypical angina. Which symptom does the nurse anticipate? (Select all that apply.) A.Vomiting B.Dizziness C.Indigestion D.Aching jaw pain E.Irregular bowel movements F.Decreased patterns of activity
B,C,D,F
Which information is most relevant for the nurse to teach a client about CPAP therapy for OSA? Select all that apply. ·A. Avoid alcoholic beverages or drugs that make you sleepy within 3 hours of bed time. ·B. Clean the mask device daily. ·C. Ensure your mask device fits tightly enough to prevent air leaks. ·D. Keep open flames such as candles out of the room when CPAP is in use. ·E. Seal the mask edges to your face with petroleum jelly. ·F. Use only sterile water in the humidifier tank. ·G. Use the CPAP during all sleep periods, especially in bed. H. Do not share your mask or tubing system with others
B,C,G,H
A 45-year-old male client having an annual physical asks the nurse about his risk for developing a myocardial infarction (MI). Which modifiable risk factors will the nurse assess to guide the client's teaching plan? Select all that apply. ·A. Age ·B. Tobacco use ·C. Gender ·D. Diet ·E. Family history ·F. Weight
B,D,F
In preparing a client with head and neck cancer (pharyngeal) for radiation therapy, which side effects does the nurse teach the client to expect? Select all that apply. · A. Scalp and eyebrow alopecia · B. Taste sensation loss or changes · C. Bloody and purulent sinus drainage · D. Increased risk for skin breakdown · E. Moderate weight gain · F. Increased risk for cavities · G. Gastroesophageal reflux H. A persistent blue tinge to the skin and mucous membranes around the mouth
B,D,F
A client who is 9 days post-coronary artery bypass graft presents to a follow-up appointment. Which client statement requires nursing action? A. "My chest hurts when I sneeze or cough." B. "If I get tired when I walk, then I stop and rest for a bit." C. "I have a bandage on my sternum to collect the drainage." D. "I haven't had my normal appetite since the surgery."
C
A client who is receiving heparin therapy is started on warfarin. Which nursing explanation is appropriate? ·A. "You will need both drugs long-term to provide long-term anticoagulation." ·B. "Warfarin is easier on your stomach so you can take it long-term." ·C. "It takes several days for warfarin to begin working, so both drugs are required for a shorttime." D. "These drugs work the same, but one is taken by mouth, so it is easier to take at home."
C
A client with COPD has all of the following ABG changes from earlier today. Which change alerts the nurse to take immediate action to prevent harm? A. pH from 7.21 to 7.20 B. HCO3- remains the same at 31 mEq/L C. Paco2 from 45 mm Hg to 68 mm Hg D. Pao2 from 88 mm Hg to 86 mm Hg
C
A client with severe angioedema and tongue swelling from a drug allergy has stridor and an oxygen saturation of 60%. For which type of respiratory support does the nurse prepare? · A. Nasal CPAP · B. Tracheotomy · C. Cricothyroidotomy · D. Endotracheal intubation
C
A nursing home client who has completed a 2-week course of antibiotics for bacterial pneumonia asks whether he can go out to a restaurant to celebrate his grandson's high school graduation if he uses a wheelchair. What is the nurse's best response? A. "No, going out now before you have recovered your strength can cause a relapse of the pneumonia." B. "No, the risk that you could spread this disease to other people is much too high." C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting." D. "Yes, if you agree to wear a face mask to prevent spreading droplets."
C
Safe and Effective Care Environment The SpO 2 of a client receiving oxygen therapy by nasal cannula at 6 L/min has dropped from 94% an hour ago to 90%. Which action does the nurse perform first to improve gas exchange before reporting the change to the primary health care provider? ·A. Tighten the straps on the nasal cannula ·B. Increase the oxygen flow rate to 8 L/min ·C. Check the tubing for kinks, leaks, or obstructions ·D. Check to determine whether the oxygen delivery system is adequately humidified
C
The client, a woman who is 5 feet 11 inches tall and 176 lb (80 kg), has been mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 12 breaths/min for the past 24 hours. The most recent arterial blood gas (ABG) results for this client are pH = 7.32; PaO 2 = 84 mm Hg; PaCO 2 = 56 mm Hg. What is the nurse's interpretation of these results? ·A. Ventilation adequate to maintain oxygenation. ·B. Ventilation excessive; respiratory alkalosis present. ·C. Ventilation inadequate; respiratory acidosis present. ·D. Ventilation status cannot be determined from information presented.
C
The nurse is assessing a client with heart failure. Which assessment data are the best indicator of fluid balance? ·A. Blood pressure 144/79 mm Hg ·B. Urine output 200 mL in the last 4 hours ·C. Weight increase of 9 lb in the past week ·D. Generalized edema in the lower extremities
C
The nurse is assessing the client's cardiac rhythm and notes the following: HR 64, regular rhythm, PR interval 0.20; QRS 0.10. How will the nurse document this rhythm interpretation in the electronic health record? ·A. Sinus tachycardia ·B. Sinus bradycardia ·C. Normal sinus rhythm ·D. Sinus arrhythmia
C
The nurse is caring for a client with many risk factors for hypertension. Which is a symptom? A.Fainting B.Vomiting C.Headache D.Speech slurring
C
The nurse is caring for four clients with a history of hypertension. Which client will the nurse see first? A.30-year-old with pre-eclampsia, BP 120/68 B.41-year-old with chronic kidney disease, BP 138/80. C.53-year-old on diuretics, BP 160/80 D.60-year-old with LDL-C 140 mg/dL, BP 114/84
C
The primary health care provider prescribes warfarin for a client with atrial fibrillation. Which client statement indicates that additional education is needed? A. "I need to go to the clinic once a week to have my blood level checked." B. "If my stools turn black, I will be sure to call my primary health care provider." C. "I'm glad I don't need to change my diet. Salads are my favorite food." D. "I need to stop taking my herbal supplement."
C
The spouse of a 78-year-old client who was discharged to home 1 day ago after hospitalization for seasonal influenza calls to report the fever has returned and is now 103.4°F (39.7°C). What is the nurse's primary concern for this client? ·A. The client may not be taking the prescribed antiviral drug correctly ·B. A second strain of influenza is likely ·C. Pneumonia may be present ·D. The client may be dehydrated
C
When performing a medication reconciliation for a newly admitted client before planned abdominal surgery, the nurse notes that the client is prescribed salmeterol and fluticasone daily for asthma control. What is the priority action for the nurse to take regarding this information to prevent harm? ·A. Record and display the information in a prominent place within the client's medical record. ·B. Ask the client how long the drugs have been prescribed and how well the asthma is controlled. ·C. Collaborate with the surgeon to arrange for continuation of this therapy in the perioperative period. ·D. Ensure that parenteral forms of these drugs are prescribed for use while the client remains NPO after surgery.
C
Which action does the nurse take care to avoid while suctioning a client's tracheostomy tube? A. Twirling the catheter while applying suction B. Applying suction only when withdrawing the catheter C. Performing oral suctioning before suctioning the artificial airway D. Lubricating the suction catheter with sterile saline before insertion
C
Which action will the nurse take when having difficulty auscultating the first heart sound, S1? A.Listen at the heart base B.Assess only for higher pitched sounds. C.Direct the client to lay on his or her left side. D.Have the client hold their breath while auscultation takes place
C
Which respiratory side effect does the nurse teach the client who is now prescribed an angiotensin-converting enzyme (ACE) inhibitor to expect? A. Wheezing on exertion B. Increased secretions C. Persistent dry cough D. Orthopnea
C
Upon entering a client's room, the nurse finds the client unresponsive. In what order will the nurse provide care? ·A. Begin chest compressions ·B. Check carotid pulse ·C. Notify the Rapid Response Team ·D. Get the crash cart/AED ·E. Provide rescue breaths
C,D,B,A,E
The nurse is caring for a diabetic client who will be discharged on hydrochlorothiazide (HCTZ). What information will the nurse include in the discharge teaching? Select all that apply. ·A. "This drug may cause a dry, nagging cough." ·B. "Take this drug with a snack, right before bed." ·C. "Try to increase your intake of potassium in your diet." ·D. "This drug can affect your glucose control." ·E. "Increased urination is expected with this drug.
C,D,E
Which actions does the nurse ensure are performed for a client being mechanically ventilated to prevent ventilator-associated pneumonia (VAP)? Select all that apply. A. Assessing temperature every 4 hours B. Checking ventilator settings every 4 hours C. Getting the patient out of bed as soon as prescribed D. Keeping the head of the bed elevated to 30 degrees or above E. Maintaining the client in the prone position F. Providing adequate humidification G. Providing meticulous mouth care every 12 hours H. Suggesting that the pneumonia vaccine be prescribed
C,D,G
Why are the terminal bronchioles more prone to collapse than are the other airways? Select all that apply. A. The cartilage is an incomplete C-shape rather than a true ring. B. The mucous membrane lining contains minimal active cilia. C. Lung elastic recoil is the only force that keeps them patent. D. Their walls are too thick to permit gas exchange. E. They are surrounded by capillaries. F. The lumens have a small diameter. G. Their walls contain no cartilage.
C,F,G
A client has just come to the floor after undergoing inner maxillary fixation for a mandibular fracture with wiring of the jaws. As the nurse raises the head of the bed, the client starts to vomit a large amount of liquid vomitus. What is the nurse's priority action? · A. Administer the prescribed antiemetic by the intravenous or rectal route. · B. Immediately notify the surgeon, the anesthesiologist, or the rapid response team. · C. Cut the wires holding his jaws together, and carefully remove them from the mouth. · D. Reposition the client to the side and suction the mouth with a large-bore catheter.
D
A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the nurse that there are no ECG complexes, and the alarm is sounding. What is the first action by the nurse? A. Suspend the alarm. B. Call the emergency response team. C. Press the record button to get an ECG strip. D. Assess the client and check lead placement.
D
A client presents to the ED and is diagnosed with an acute MI. The client's spouse asks what type of damage has been caused by the "heart attack." What is the appropriate nursing response? A."The pain is controlled, so there is no damage." B."It will take years to know the extent of the damage to the heart muscle." C."The medication will dilate the blood vessels so damage will be corrected." D."A heart attack evolves over several hours. We won't know the extent of the damage immediately."
D
An attempt by a primary health care provider to intubate a client for mechanical ventilation is unsuccessful after 45 seconds. What is the nurse's priority action? A. Placing a nasotracheal tube B. Assessing for bilateral breath sounds C. Assessing oxygen saturation by pulse oximetry D. Applying oxygen with a bag-valve-mask device
D
The nurse is caring for a client with intermittent claudication due to peripheral arterial disease. Which client statement indicates understanding of proper self-management? ·A. "I need to reduce the number of cigarettes that I smoke each day." ·B. "I'll elevate my legs above the level of my heart." ·C. "I'll use a heating pad to promote circulation." ·D. "I'll start to exercise gradually, stopping when I have pain."
D
The nurse is caring for client who is experiencing occasional premature ventricular contractions. What assessment data are most concerning to the nurse? ·A. Potassium 4.8 mEq/L ·B. Magnesium 2 mEq/L ·C. Heart rate 90 ·D. History of smoking
D
The nurse is teaching a client with stage 1 hypertension. Which client statement indicates understanding of dietary modifications? · A. "I will reduce my sodium intake to 2500 mg per day." · B. "I will restrict my intake of daily dietary lean protein." · C. "I am only going to drink one cup of coffee to start my day." · D. "I will drink a glass of low-fat milk with my breakfast."
D
When assessing the client 2 hours after a thoracentesis, the nurse notes the skin around the puncture site is swollen and a crackling is felt and heard when pressure is applied to the area. What is the nurse's best action? ·A. Assess the client's SPO 2 levels at two separate sites. ·B. Obtain a prescription to culture the site. ·C. Document the finding as the only action. ·D. Notify the respiratory health care provider.
D
Which action does the nurse use to prevent harm by loss of tracheal tissue integrity in a client with a tracheostomy? ·A. Providing meticulous oral care every 8 hours ·B. Deflating the cuff for 15 minutes every 2 hours ·C. Feeding the client liquids rather than solid foods ·D. Maintaining cuff inflation pressure less than 25 cm H2O
D
Which assessment finding for a client receiving oxygen therapy with a nonrebreather mask requires the nurse to intervene immediately? A. The oxygen flow rate is set at 12 L/min. B. The exhalation ports are open during exhalation. C. The exhalation ports are closed during inhalation. D. The reservoir bag is not inflated during inhalation.
D
Which nursing action has the highest priority when caring for a client with any type of facial or laryngeal trauma? ·A. Managing pain ·B. Providing nutrition ·C. Assessing self-image ·D. Maintaining a patent airway
D
· When making rounds, the nurse observes that a cognitively impaired client has a partial airway obstruction from inspissation. What is the nurse's priority action? · A. Place the bed in reverse Trendelenburg position and apply humidified oxygen by nasal cannula. · B. Check the flow sheet to assess for trends in the client's oxygen saturation patterns. · C. Determine which assistive personnel (AP) provided this client's morning care today. · D. Immediately provide complete oral care to this client.
D
A client with primary pulmonary arterial hypertension (PAH) receiving treprostinil by continuous IV infusion now has a fever of 101.6°F (38.7°C). Which actions will the nurse perform to prevent harm? Select all that apply. ·A. Administer the prescribed antipyretic ·B. Ask the client whether a productive cough is present ·C. Apply oxygen by nasal cannula ·D. Culture the IV site ·E. Determine whether a durable power of attorney has been signed ·F. Increase the treprostinil flow rate ·G. Initiate a second IV access and administer prescribed antibiotic ·H. Place the client in protective isolation
D,F,G
Which statements about oxygen and oxygen therapy are true? Select all that apply. ·A. An oxygen concentrator reduces the amount of carbon dioxide in atmospheric air. ·B. Clients must provide informed consent to receive oxygen therapy. ·C. Excessive oxygen use is a contributing cause of chronic obstructive pulmonary disease. ·D. In nonemergency situations, a health care provider's prescription is needed for oxygen therapy. ·E. Oxygen can explode when handled improperly. ·F. Oxygen is a beneficial element but can harm lung tissue. ·G. The liquid form of oxygen is a drug to manage hypoxia, whereas the gaseous form is only an atmospheric element. ·H. Unless humidity is added, therapy with oxygen dries the upper and lower mucous membranes.
D,F,H
