MS E2 Practice
A client is being treated for a pulmonary embolism and the medical nurse is aware that the client suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology?
Adequate flow of blood through the pulmonary circulation.
Post transfusion, the donor stands up immediately after the needle is withdrawn. The nurse should be alert for which vital sign change?
Decreased blood pressure.
A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
Decreased serum calcium level
High or increased compliance occurs in which disease process?
Emphysema
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this dient with tenacious bronchial secretions?
Encouraging the client to drink 2 to 3 L of water dally
A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?
Preoxygenate the client with 100% oxygen for up to 3 min.
A nurse is admitting a client who is having an exacerbation of his asthma. when reviewing the providers orders the nurse recognizes that clarification is needed for which of the following medications?
Propanolol
A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this conditions?
Severe dyspnea Decreased LOC Headache Hypotension
A nurse is assessing a client who has COPD. The nurse should expect the clients chest to be which of the following shapes?
barrel chest
A client with emphysema is at a greater risk for developing which acid-base imbalance?
chronic respiratory acidosis
A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. which of the following medications should the nurse administer first?
epi
A nurse is teaching a client scheduled for an activated partial thromboplastin time (aPTT). Which of the following statements by the client indicates an understanding of the teaching?
it measures deficiencies in clotting factors
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?
pH 7.28, PaO2 50 mm Hg
A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include?
"'Limit water intake with meals."
You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response?
"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe."
A client verbalizes fear of infection from a blood transfusion. What is the nurse's best response?
"Every unit of donated blood is typed and tested for antibodies to infections."
A client newly diagnosed with COPD tells the nurse, "I can't believe I have COPD; I only had a cough. Are there other symptoms I should know about"? Which is the best response by the nurse?
"Other symptoms you may develop are shortness of breath upon exertion and sputum production."
A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?
*If could lose about 50 pounds. I might stop having so many apneic episodes
A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications?
-Elevate the HOB to at least 30 -Administer pantoprazole as prescribed -Reposition the endotracheal tube to the opposite side of the mouth daily
A nurse is planning care for a client who is receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?
4 hr
The nurse is assessing a client whose respiratory disease is characterized by chronic hyperinflation of the lungs. Which physical characteristic would the nurse most likely observe in this client?
A barrel chest
Which statement describes emphysema?
A disease of the airways characterized by destruction of the walls of overdistended alveoli
A nurse is preparing to administer 2 units of packed RBCs to an older adult client. Which of the following actions should the nurse take?
Administer each unit over 3 hr.
After receiving a dose of penicillin, a client develops dyspnea and hypotension and the nurse suspects the client is experiencing anaphylactic shock. What is the nurse's first action?
Administer epinephrine, as ordered.
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
Administer oxygen therapy
A nurse is caring for a female client in the emergency department who reports SOB & pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her HR is 110/min, RR 40/min & BP 140/80 mmhg. Her arterial blood gases are pH 77.50, paCO2 29 mmHg, PaO2 60 mmHg, HCO3 20mEq/L, and SaO2 86%. Which of the following is the priority is the priority nursing intervention?
Administer oxygen via face mask.
A nurse is an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurses highest priority?
Administering a nebulized beta-adrenergic
A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms?
Albuterol via jet nebulizer
A client newly diagnosed with emphysema asks the nurse to explain all about the disease. The nurse would include the following response when defining emphysema:
An abnormal distention of the air spaces with destruction of the alveolar walls
A client arrives in the emergency room with emphysema and has developed an exacerbation of COPD with respiratory acidosis from airway obstruction. What is the highest priority for the nurse?
Apply supplemental oxygen as ordered.
A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
As soon as the nurse can prepare the client and the administration set.
A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing, Which of the following actions is the nurse's priority?
Assess the client's respiratory status
The ED nurse is assessing the respiratory function of a client who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive of what condition?
Asthma
The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction and that leads to the collapse of alveoli. What complication should the nurse monitor for?
Atelectasis
A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma?
Bilateral wheezes
A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Blood pressure 115/68 mmlg
Which statement is true about both lung transplant and bullectomy?
Both procedures improve the overall quality of life of a client with COPD.
The nurse is caring for a client suspected of having acute respiratory distress syndrome (ARDS). What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the client's symptoms from those of a cardiac etiology?
Brain natriuretic peptide (BNP) level
The nurse hears the alarm sound on the telemetry monitor and observes a flat line. The patient is found unresponsive, without a pulse, and no respiratory effort. What is the first action by the nurse?
Call for help and begin chest compressions.
A nurse is assessing a client who is receiving a platelet transfusion. Which of the following findings is an adverse effect of the transfusion?
Chills
A nurse is planning care for a client who has dee-vein thrombosis (DVT) and is receiving anticoagulation therapy. Which of the following?
Encourage the client to walk.
A nurse finds a client with absent breathing and prepares to begin one-person cardiopulmonary resuscitation. What will the nurse do first?
Establish unresponsiveness.
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
Excessive thrombosis and bleeding
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?
Extreme anxiety
A nurse is teaching a client who has asthma how to use a metered-dose inhaler (MDI). The nurse identifies the sequence of steps the client should follow.
Inhale deeply and then exhale completely. Place her lips firmly around the mouthplece. Breathe in deeply over 2 to 3 seconds while pushing down on the canister. Hold her breath for 10 seconds. Exhale slovy through pursed lips Wait 60 asconds between each puff.
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?
Initiate oxygen therapy.
A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?
Instruct the client to use pursed-lip breathing.
A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect?
Intercosta retractions
A nurse is caring for a young female adult client who reports weakness fatigue and heavy menstrual periods the client has hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspect which of the following types of anemia?
Iron-deficiency anemia
The staff educator is teaching a class in arrhythmias. What statement is correct for defibrillation?
It is used to eliminate ventricular arrhythmias.
The nurse is aware that a religious group that refuses blood transfusions for religious reasons is:
Jehovah's Witnesses
A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?
Lethargy
A nurse is caring for a client who has asthma and is taking fluticasone. the nurse should monitor the client for which of the following adverse effects?
Orla Candidiasis
Hyperresonance is audible when which area is percussed?
Overinflated lung tissue
A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus?
Oxygen is dissolved. Oxyhemoglobin circulates to the body tissue. Adequate red blood cells are needed for oxygen transport.
A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?
Packed RBCs
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?
Place in prone position
The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition?
Pneumothorax
The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear external pneumatic compression stockings. The nurse should explain that refusing to wear external pneumatic compression stockings increases the risk of which postsurgical complication?
Pulmonary embolism
A nurse is creating a dietary plan for an adult female client who has a hemoglobin level of 9.8 g/dL. Which of the following foods should the nurse recommend?
Raisins
A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings is a manifestation of a hemolytic transfusion reaction?
Report of low-back pain
A nurse is assessing a client who has chronic bronchitis. Which of the following percussion sounds should the nurse expect?
Resonance
A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?
Respiratory rate of 22 breaths/minute
When a disease infects a host a portal of entry is needed for an organism to gain access. What has been identified as the usual portal of entry for tuberculosis?
Respiratory system
A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medication should the nurse plan to administer?
Rifampin Isoniazid Pyrazinamide
A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated?
Skin tenting present
A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action?
Slow the infusion rate and monitor the client closely.
A nurse is giving a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder?
Smoking cessation
A client on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease?
Standard and airborne precautions
A nurse is discussing asthma complications with a client and family. What complications should the nurse include in the teaching? Select all that apply.
Status asthmaticus Respiratory failure Atelectasis
A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the clients blood pressure is 80/64 mmHg. Which of the following actions should the nurse take first?
Stop the infusion of blood
A nurse is administering platelets to a client who reports having lower back pain and feeling chilled and itchy. Which of the following actions should the nurse take first?
Stop the infusion.
A 18-year-old client presents to the emergency department with a severe open fracture of the lower extremity. The health care provider tells the client that the client will need a blood transfusion. The client refuses, despite the advise of the health care provider. What does the nurse understand is the legal implication of the scenario?
The client has a right to refuse the transfusion.
A nurse is preparing to administer warfarin to a client. Which of the following information should the nurse recognize prior to administering the medication?
The client should be observed for manifestations of hemorrhage.
A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?
The first 15 min
A client is placed in isolation for suspected tuberculosis. Which action should the nurse take when entering the client's room?
Wear an N95 respirator.
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
a room with air exhaust directly to the outdoor environment
A nurse is reviewing a clients laboratory results and finds the hemoglobin is 10 g/dL and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following?
cellular hypoxia
A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation:
is breathing air in and out of the lungs.
A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?
provide high-flow oxygen
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
"DIC is caused by abnormal coagulation involving fibrinogen."
A patient develops gastrointestinal bleeding from a gastric ulcer and requires blood transfusions. The patient states to the nurse, "I am not going to have a transfusion because I don't want to get AIDS." What is the best response by the nurse?
"I understand your concern. The blood is screened very carefully for different viruses as well as HIV."
A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
"I won't donate blood because I don't want to get AIDS."
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?
Agitation
Which type of chest configuration is typical of a client with COPD?
Barrel chest
Which assessment finding would be most consistent with advanced emphysema?
Barrel-shaped chest
A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client?
Continuous positive airway pressure (CPAP)
The nurse understands that asystole can be caused by several conditions. Select all that apply.
Hypoxia Hypovolemia Hypothermia Acidosis
Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia?
Monitor vital signs and cardiac rhythm
Which is the most important risk factor for development of chronic obstructive pulmonary disease (COPD)?
Cigarette smoking
The nurse knows that what condition is associated with increased compliance of the lungs?
Emphysema
A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?
Hemolytic
A nurse in a providers office is assessing a client. the nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis?
Night sweats, low-grade fever, blood in the sputum
A nurse is caring for a client who reports an arca of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?
Obtain a venous duplex ultrasound.
A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is quallfied?
Oncology nurse
The nurse began transfusing the first unit of packed red blood cells (PRBCs) fifteen minutes ago. The client reports shortness of breath, nausea, and is restless. What is the nurse's priority action?
Stop the infusion.
The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and reports severe chest tightness. What is the most appropriate initial action for the nurse to take?
Stop the transfusion immediately.
A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?
Stopping the transfusion
A nurse at a blood donation center is screening clients for blood donation. The nurse should identify that which of the following clients must reschedule donation?
cient wino has an oral témperature of 37.8° C (1001 F)
A nurse enters a clients room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first?
Check for carotid pulse
A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take?
Check vital signs before transfusion Insert an IV with a 19 gauge needle Check the expiration date of the blood product with a second nurse
A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin and pyrazinamide. Which of the following instructions should the nurse include?
Drink at least 8 ounces of water when you take the pyrazinamide tablet
The intensive care nurse is responsible for the care of a client who is in shock. What cardiac signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply.
Drop in systolic blood pressure of ≥40 mm Hg from baselines Serum lactate >4 mmol/L Mean arterial pressure (MAP) of ˂65 mm Hg
A junior-level nursing class has just finished learning about the management of clients with chronic pulmonary diseases. They learned that a new definition of COPD leaves only one type of disorder within its classification. Which of the following is part of that disorder?
Emphysema
A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?
Fatigue
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?
Heparin
A client is in the hospital with a bleeding gastric ulcer and requires a blood transfusion. He has been typed and crossmatched for 2 units of packed red blood cells and found to have type O blood. What type of blood will the nurse administer to this client?
Type O
A nurse is teaching a client who has chronic obstructive pulmonary disease and is to start using fluticasone by MDI twice daily. Which of the following instructions should the nurse include?
inspect your mouth for lesions daily.
A nurse in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interaction risks and should instruct the client to avoid which of the following?
Cabbage
The nurse is caring for a client who ahs heart failure and a history of asthma. The nurse reviews the providers orders and recognizes that clarification is needed for which of the following medications?
Carvedilol
A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?
Chest pain and dyspnea
The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?
Cyanosis
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
Generalized urticaria.
What is the treatment of choice for ventricular fibrillation?
Immediate bystander CPR
A nurse is caring for a client who is at risk for shock. Which of the following findings is the earllest indicator that this complication is developing?
Increased respiratory rate
A nurse is assessing a client who has a fracture of the femur. The nurse obtains vitals signs on admission and again in 3 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?
Increased respiratory rate from 18 to 44 / min.
A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. What is the priority nursing concern with this client?
Ineffective breathing pattern
A nurse is performing pulmonary hygiene for a client who has pneumonia and positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position?
Lateral segment of the right lower lobe
A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
Onguria
A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?
Stridor
A client has tested positive for tuberculosis (TB). While providing client teaching, which information should the nurse prioritize?
The importance of adhering closely to the prescribed medication regimen
The nurse is assisting in the care of a client who is receiving cardiopulmonary resuscitation (CPR). For which reason will the client be prescribed to receive amiodarone during the resuscitation efforts?
Treat pulseless ventricular tachycardia.
A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client's PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious administering oxygen?
Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia.
The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?
Lungs and kidney
A nurse is developing the teaching portion of a care plan for a client with COPD. What would be the most important component for the nurse to emphasize?
Chronic inhalation of indoor toxins can cause lung damage.
The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as?
Clubbing
The nurse is caring for a client who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign or symptom should the nurse monitor?
Hypothermia
A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching?
I will follow a daily diet high in calories and protein.
A nurse is teaching a client who has chronic obstructive pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching?
I will take my bronchodilators after meals\
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?
Manual resuscitation bag
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE. The nurse should instruct the client to avoid which of the following unsafe actions?
Massaging her legs
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?
Oral mucosa
A nurse who works in an oncology practice prepares patients for the side effects of adjuvant hormonal therapy to treat breast cancer. Which of the following is the hormonal agent that has an increased risk of pulmonary embolism and deep vein thrombosis?
Tamoxifen
For a client with chronic obstructive pulmonary disease, which nursing intervention helps maintain a patent airway?
Teaching the client how to perform controlled coughing
A nurse is caring for an older adult with emphysema. Which nursing action demonstrates primary prevention?
Teaching the client various methods to help prevent pneumonia
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
Temperature
A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation:
Tense and relax muscles in the lower extremities.
A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information?
The student should use his quick relief inhaler The students asthma is not well controlled The students peak flow is 50% to 80% of his best peak flow The nurse should obtain a second expiratory flow rate
A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?
Tuberculosis
Nursing students are reviewing the various infectious diseases that require transmission-based precautions. The students demonstrate understanding of the information when they identify which infectious disease as requiring airborne precautions?
Tuberculosis
A nurse is teaching a client who will undergo a bronchoscopy procedure. The provider will use a rigid scope and general anesthesia. The nurse should explain that the clients neck will be in which of the following positions?
hyperextension
A nurse is preparing to administer a unit of red bloods cells. The nurses responsibility is to compare and verify the information on the blood label with the clients information. The nurse should use which of the following as the priority source of verification?
identification wristband
A nurse enters an adult clients room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first?
summon the code team
A client presents to the emergency department after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling of not being able to breathe enough. The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of which respiratory problem?
Acute respiratory failure
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the clients restored rhythm is symptomatic bradycardia?
Atropine
A nurse provides morning care for a client in the intensive care unit (ICU). Suddenly, the bedside monitor shows ventricular fibrillation and the client becomes unresponsive. After calling for assistance, what action should the nurse take next?
Begin cardiopulmonary resuscitation
The nurse in the intensive care unit (ICU) hears an alarm sound in the patient's room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on the monitor. What is the first action by the nurse?
Begin cardiopulmonary resuscitation (CPR)
A nurse is performing cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client circulation by palpating which of the following pulses?
Carotid
A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurse's priority intervention?
Count the respiratory rate.
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?
Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing
A client is receiving the first of two prescribed units of PRBCs. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action?
Discontinue the transfusion.
A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?
Increased anteroposterior diameter of the chest
A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure?
Sudden onset of lung impairment in a client who had normal lung function
A nurse is reviewing the PT, aPTT, and IN laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?
The laboratory values are prolonged.
A nurse is monitoring a client who is receiving packed RBCs. The nurse identifies which of the following as an expected finding?
The pacjed RBCs are connected by Y tubing to normal saline
A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient?
Ventilation exceeds perfusion.
A nurse is preparing to administer blood to a client. Which of the following actions should the nurse take to identify the client?
Verify the provider's prescription with another RN. Scan the barcode on the client's identification band Compare client identification number to the blood component tag number
A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client?
a. dyspnea c. barrel chest d. clubbing of the fingers
A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?
auscultate for wheezing
A nurse is preparing an adolescent client who has pneumonia for percussion, vibration and postural drainage. Prior to the procedure which of the following nursing actions should the nurse complete first?
auscultate lung fields
A client with severe anemia is prescribed 2 units of packed red blood cells. The client refuses to sign the consent form for blood administration because to do so conflicts with the client's Jehovah's Witness faith. What did the nurse fail to assess prior to witnessing consent?
cultural beliefs
A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?
confusion
A nurse in a providers office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?
confusion
A nurse in the emergency department is assessing an older adult client who has community acquired pneumonia. Which of the following findings should the nurse expect?
confusion
