NUR 240 exam 2
The nurse is caring for a client receiving continuous tube feeding. The client has a gastric residual of 550 mL. The previous residual was 200 mL. What action should the nurse take?
Hold the enteral nutrition and notify the primary care provider.
A client has been on a clear liquid diet for 5 days. What is an appropriate nursing diagnosis for this client?
Imbalanced Nutrition, Less Than Body Requirements
incentive spirometry
Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?
Nasal cannula
The nurse should assess for respiratory depression before and after the administration of which drugs?
Opioid analgesics
A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?
Pleural effusion
When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing
Poor tissue perfusion
When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?
Rapid respirations
The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?
Resiual Volume (RV)
Which laboratory test is the best indicator of a client in need of TPN?
Serum albumin
Total parenteral nutrition (TPN)
TPN is nutritional therapy that bypasses the gastrointestinal tract and is administered through a central vein.
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?
Ambu bag
A nurse documents a client's hemoglobin as 80 g/L. What nutritional condition does this biochemical data signify?
Anemia
A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching?
Blood from the fingertips shows changes in glucose more quickly than other testing sites.
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
They are low-pitched, soft sounds heard over peripheral lung fields.
A physician orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition?
Total parenteral nutrition (TPN)
A client is prescribed warfarin, an anticoagulant. When educating this client about potential diet and drug interactions, the nurse would caution the client about foods containing which nutrient?
Vitamin K
A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:
bronchospasms
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:
congestive heart failure
A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:
croup
Which skin disorder is associated with asthma?
eczema
A nurse is managing a client's continuous tube feeding via an NG tube. How often should the nurse check for residual?
every 4-6 hours
The nurse is preparing to provide hygiene care to a client with hypoxia. Into what position will the nurse place the client?
high Fowlers
The nurse is caring for a client who is diagnosed with impaired gas exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?
high respiratory rate
A client has a gastrostomy tube in place for intermittent tube feedings. What action should the nurse take prior to administering a tube feeding to ensure that the tube has not migrated?
mark the length of tube and assess if it at the level of the abdomen
An older adult client has a decubitus ulcer with drainage, dysphagia, and immobility. She consumes less than 300 calories per day and has a large amount of interstitial fluid. The client is in a state of
negative nitrogen balance.
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of:
pneumonia
The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly?
respirations are at 20 breaths per minute
The nurse is caring for a client who was had a percutaneous tracheostomy (PCT) following a motor vehicle accident, and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?
tracheostomy collar
