Pop 3 Exam 5 Questions

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an order is for 750mg of an antibiotic to be given to a patient with an empyema. the medication is available as 500mg/10mL. how many ML will the nurse administer?

A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate? a. "Infertility can result from some medications used to control your disease." b. "Temporary remission of your signs and symptoms is common during pregnancy." c. "Autoantibodies transferred to the baby during pregnancy will cause heart defects." d. "The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth."

A 25-yr-old female patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, "I never leave my house because I hate the way I look." The nurse will plan interventions with the patient to address the nursing diagnosis of a. social isolation. b. activity intolerance. c. impaired skin integrity. d. impaired social interaction.

The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) a. Neurologic system b. Endocrine system c. Pulmonary system d. Immune system e. Cardiovascular system f. Hepatic system

A, c, e

A patient with systemic lupus erythematosus (SLE) is admitted to the hospital with acute joint inflammation. Which information obtained in the lab testing with be of highest concern to the nurse? a. elevated blood urea nitrogen BUN level b. increased C-reactive protein level c. positive nuclear antibody test result d. positive lupus erythematosus cell preparation

During a visit to a 78-yr-old patient with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of "feeling too tired to get out of bed." Based on these data, a correct nursing diagnosis for the patient is a. activity intolerance related to fatigue. b. impaired skin integrity related to edema. c. disturbed body image related to weight gain. d. impaired gas exchange related to dyspnea on exertion.

During an acute exacerbation, a patient with SLE is treated with corticosteroids. The nurse would expect corticosteroids to begin to be tapered when which serum lab results are evident? a. Decreased anti-DNA b. Increased Complement c. Increased RBC d. Decreased ESR

During assessment of the patient with scleroderma, what should the nurse expect to find? a. thickening of the skin of the fingers and hands b. cool, cyanotic fingers with thinning skin over the joints c. swan neck deformity or ulnar drift deformity of the hands d. low back pain, stiffness, and limitation of spine movement

The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? A patient with a. chronic lung disease with increased carbon dioxide retention b. acute anxiety, hyperventilation, and decreased carbon dioxide retention c. decreased cardiac output with increased serum lactic acid production d. gastric drainage with increased removal of gastric acid

The clinic nurse teaches a patient with a 42 pack-year history of cigarette smoking about lung disease. Which information will be most important for the nurse to include? a. Options for smoking cessation b. Reasons for annual sputum cytology testing c. Erlotinib (Tarceva) therapy to prevent tumor risk d. Computed tomography (CT) screening for lung cancer

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment would best evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Review hemoglobin and hematocrit values.

The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. Oxygen saturation is 88%. b. Blood pressure is 145/90 mm Hg. c. Respiratory rate is 22 breaths/minute when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.

The nurse is assessing a patient's differential white blood cell count. What implications would this test have on evaluating the adequacy of a patient's gas exchange? a. An elevation of the total white cell count indicates generalized inflammation. b. Eosinophil count will assist to identify the presence of a respiratory infection. c. White cell count will differentiate types of respiratory bacteria. d. Level of neutrophils provides guidelines to monitor a chronic infection.

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Document the amount of drainage every eight hours. b. Obtain samples of drainage for culture from the system. c. Assess patient pain level associated with the chest tube. d. Check the water-seal chamber for the correct fluid level.

The nurse is reviewing the patient's arterial blood gas results. The PaO2 is 96 mm Hg, pH is 7.20, PaCO2 is 55 mm Hg, and HCO3 is 25 mEq/L. What would the nurse expect to observe on assessment of this patient? a. Disorientation and tremors b.Tachycardia and decreased blood pressure c.Increased anxiety and irritability d. Hyperventilation and lethargy

The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests they should a. avoid activities requiring repetitive use of the same muscles and joints. b. protect the knee joints by sleeping with a small pillow under the knees. c. stand rather than sit when performing daily household and yard chores. d. strengthen small hand muscles by wringing out sponges or washcloths.

The nurse would identify which patient as having a problem of impaired gas exchange secondary to a perfusion problem? A patient with a. peripheral arterial disease of the lower extremities b. chronic obstructive pulmonary disease (COPD) c. chronic asthma d. severe anemia secondary to chemotherapy

What is the pathophysiology of SLE characterized by? a. Destruction of nucleic acids and other self-proteins by autoantibodies b. Overproduction of collagen that disrupts the functioning of internal organs c. Formation of abnormal IgG that attaches to cellular antigens, activating complement d. Increased activity of T suppressor cells with B cell hypoactivity, resulting in immunodeficiency

What should the nurse include in the teaching plan for the patient with SLE? a. Ways to avoid exposure to sunlight b. Increasing dietary protein and carb intake c. The necessity of genetic counseling before planning a family d. The use of nonpharmacologic pain interventions instead of analgesics

Which action should the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? a. Monitor blood pressure frequently. b. Encourage patient to ambulate in room. c. Titrate nesiritide slowly before stopping. d. Teach patient about home use of the drug.

Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most immediate action by the nurse? a. O2 saturation of 88% b. Weight gain of 1 kg (2.2 lb) c. Heart rate of 106 beats/min d. Urine output of 50 mL over 2 hours

Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis is likely to be an adverse effect of the medication? a. Blurred vision b. Joint tenderness c. Abdominal cramping d. Elevated blood pressure

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctu- ation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart.

Which patient would the nurse identify as being at an increased risk for altered transport of oxygen? A patient with a. hemoglobin level of 8.0 b. bronchoconstriction and mucus c. peripheral arterial disease d. decreased thoracic expansion

A nurse assesses a patient with joint pain and stiffness who was diagnosed with stage III rheumatoid arthritis (RA). Which additional characteristics should the nurse expect? (SATA) a. Presence of nodules b. Consistent muscle strength c. Localized disease symptoms d. No destructive changes on x-ray e. Subluxation of joints without fibrous ankyloses f. Joint space narrowing and formation of osteophytes

A, e

A 29-yr-old woman is taking methotrexate to treat rheumatoid arthritis. Which information from the patient's health history is important for the nurse to report to the HCP r/t the methotrexate? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to get pregnant before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

A patient has scleroderma manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action will the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep the environment warm and draft free. c. Obtain capillary blood glucose before meals. d. Assist to bathroom every 2 hours while awake.

A patient in the clinic with cystic fibrosis (CF) reports increased sweating and weakness during the summer months. Which action by the nurse would be most appropriate? a. Teach the patient signs of hypoglycemia. b. Have the patient add dietary salt to meals. c. Suggest decreasing intake of dietary fat and calories. d. Instruct the patient about pancreatic enzyme replacements.

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patient's bed at no more than 30 degrees elevation.

A patient is recovering from an acute exacerbation of RA tells the nurse that she is too tired to bathe, What should to nurse do? a. Give the patient a bath to conserve her energy b. Allow the patient a rest period before showering with the nurse's help c. Tell the patient that she can skip bathing if she will walk in the hall later d. Inform the patient that is important for her to maintain self-care activities

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? a. Start a peripheral IV line to administer the necessary sedative drugs. b. Position the patient sitting upright on the edge of the bed and leaning forward. c. Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. d. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.

A patient with newly diagnosed SLE asks the nurse how the disease will affect her life. What is the best response? a. You can plan to have a near normal life since SLE rarely causes death b. It is difficult to tell because the disease is so variable in its severity and progression c. Life span is shortened somewhat in people with SLE but the disease can be controlled with long-term use of corticosteroids d. Most people with SLE have alternating periods of remissions and exacerbations with rapid progression to permanent organ damage

A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which response by the nurse is best? a. "Would you like to talk to the hospital chaplain about your feelings?" b. "Can you tell me what it is that makes you think you will die so soon?" c. "Are you afraid that the treatment for your cancer will not be effective?" d. "Do you think that taking an antidepressant medication would be helpful?"

A patient with two school-age children has recently been diagnosed with rheumatoid arthritis (RA) and tells the nurse that home life is very stressful. Which initial response by the nurse is most appropriate? a. "You need to see a family therapist for some help with stress." b. "Tell me more about the situations that are causing you stress." c. "Your family should understand the impact of your rheumatoid arthritis." d. "Perhaps it would be helpful for your family to be involved in a support group."

A young adult female patient with cystic fibrosis (CF) tells the nurse that she is considering getting married and wondering about having children. Which initial response by the nurse is best? a. "Are you aware of the normal lifespan for patients with CF?" b. "Would like more information to help you with that decision?" c. "Many women with CF do not have difficulty conceiving children." d. "You will need to have genetic counseling before making a decision."

After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first? a. A patient who reported dizziness after receiving the first dose of captopril b. A patient who is cool and clammy, with new-onset confusion and restlessness c. A patient who has crackles bilaterally in the lung bases and is receiving oxygen. d. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62

After teaching a patient with RA about the prescribed therapeutic regimen, the nurse determines that further instruction is needed when the patient says: a. It is important for me to perform by prescribed exercises daily b. I should perform most of my daily chores in the morning when my energy level is highest c. An ice pack to a joint for 10 minutes may help to relieve pain and inflammation when I have an acute flare d. I can use assistive devices such as padded utensils, electric can openers, and elevated toilet seats to protect my joints

Initiation of subq etanercept for patient with RA is being considered. Which patient information is most important for the nurse to communicate with the HCP? a. the patient is currently taking methotrexate b. the patient has a positive TB skin test result c. the patient has had type 2 diabetes for 5 years d. the patient is anxious about having to self-inject

The nurse assesses a 24-year-old patient with RA who is considering using methotrexate for treatment. Which patient information is most important to communicate to the health care provider? a. the patient has many concerns about the safety of the drug b. the patient has been trying to get pregnant c. the patient takes a daily multivitamin tablet d. the patient says that she has taken methotrexate in the past

The nurse determines additional instruction is needed when a patient diagnosed with scleroderma makes which statement? a. "Paraffin baths can be used to help my hands." b. "I should lie down for an hour after each meal." c. "Lotions will help if I rub them in for a long time." d. "I should perform range-of-motion exercises daily."

The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Insert nasogastric tube for feedings for patients with swallowing problems.

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)

The nurse suggests that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day with a. a brief routine of isometric exercises. b. a warm bath followed by a short rest. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness

When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of a patient. Which action, if performed by the student nurse, would require an intervention by the nurse? a. The patient is offered a tissue from the box at the bedside. b. A surgical face mask is applied before visiting the patient. c. A snack is brought to the patient from the unit refrigerator. d. Hand washing is performed before entering the patient's room.

When teaching the patient with newly diagnosed heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include a. canned and frozen fruits. b. yogurt and milk products. c. fresh or frozen vegetables. d. eggs and other high-protein foods.

Which action will the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)? a. Instruct the patient to purchase a soft mattress. b. Encourage the patient to take a nap in the afternoon. c. Teach the patient to use lukewarm water when bathing. d. Suggest exercise with light weights several times daily.

Which assessment data indicate that the chest tubes have been effective in treating the client with a hemothorax who has a right-sided chest tube? 1. There is gentle bubbling in the suction compartment. 2. There is no fluctuation (tidaling) in the water-seal compartment. 3. There is 250 mL of blood in the drainage compartment 4. The client is able to deep breathe without any pain.

Which assessment information obtained by the nurse indicates a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone? a. The patient has joint pain and stiffness. b. The patient's blood glucose is 165 mg/dL. c. The patient has experienced a recent 5-pound weight loss. d. The patient's erythrocyte sedimentation rate (ESR) has increased.

Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? a. Even, unlabored respirations c. Absence of wheezes or crackles b. Pulse oximetry reading of 92% d. Respiratory rate of 18 breaths/min

Which information will the nurse include when preparing teaching materials for a patient with an exacerbation of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Applying cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

Which laboratory result will the nurse monitor to determine if prednisone has been effective for a patient with an acute exacerbation of rheumatoid arthritis? a. Blood glucose b. C-reactive protein c. Serum electrolytes d. Liver function tests

Which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a patient with scleroderma? a. Monitor for difficulty in breathing. b. Document the patient's oral intake. c. Check finger strength and movement. d. Apply capsaicin (Zostrix) cream to hands.

Which result for a patient with systemic lupus erythematosus (SLE) is most important for the nurse to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep

Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient has understood the nurse's teaching about the condition? a. "I will exercise even if I am tired." b. "I will use sunscreen when I am outside." c. "I should avoid nonsteroidal antiinflammatory drugs." d. "I should take birth control pills to avoid getting pregnant."

A patient with RA has articular involvement. The nurse recognizes these characteristic changes include (SATA) a. bamboo-shaped fingers b. metatarsal head dislocation in feet c. noninflammatory pain in large joints d. asymmetric involvement of small joints e. morning stiffness lasting 60 minutes or more

B, e

The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a. Respiratory rate is 24 breaths/min. b. Oxygen saturation level is 98%. c. The right side of the thorax expands slightly more than the left. d. Trachea is just to the left of the sternal notch. e. Nail beds are pink with good capillary refill. f. There is presence of quiet, effortless breath sounds at lung base bilaterally.

B, e, f

A 53-yr-old patient with stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is most accurate? a. "Your heart failure has not reached the end stage yet." b. "You could not manage the multiple complications of that surgery." c. "The suitability of a heart transplant for you depends on many factors." d. "Because you have diabetes, you would not be a heart transplant candidate."

A 70 year old patient is being evaluated for symptoms of RA. The nurse recognizes what as the major problem in the management of RA in the older adult? a. RA is usually more severe in older adults b. Older patients are not as likely to comply with treatment regimens c. Drug interactions and toxicity are more likely to occur with multidrug therapy d. Laboratory and other diagnostic tests are not effective in identifying RA in older adults

A new clinic patient with joint swelling and pain is being tested for systemic lupus erythematosus. Which test will provide the most specific findings for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep

A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injections for the nodules. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodules.

A patient has recently started on digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril for the management of heart failure. Which assessment finding by the home health nurse is a priority to communicate to the health care provider? a. Presence of 1+ to 2+ edema in the feet and ankles b. Palpable liver edge 2 cm below the ribs on the right side c. Serum potassium level 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate? a. Document the presence of a large air leak. b. Notify the surgeon of a possible pneumothorax. c. Take no further action with the collection device. d. Adjust the dial on the wall regulator to decrease suction.

A patient who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as a. orthopnea. b. pulsus alternans. c. paroxysmal nocturnal dyspnea. d. acute bilateral pleural effusion.

A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action should the nurse do first? a. Auscultate the abdomen. b. Check the capillary refill. c. Auscultate the breath sounds. d. Ask about the patient's allergies.

A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-lb weight gain in the past 3 days. The nurse's priority action will be to a. have the patient recall the dietary intake for the past 3 days. b. ask the patient about the use of the prescribed medications. c. assess the patient for clinical manifestations of acute heart failure. d. teach the patient about the importance of restricting dietary sodium.

A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250 mg/dL. Which nursing action will the nurse plan to implement? a. Discuss the role of diet in blood glucose control. b. Evaluate the patient's use of pancreatic enzymes. c. Teach the patient about administration of insulin. d. Give oral hypoglycemic medications before meals.

A patient with heart failure has a new order for captopril 12.5 mg PO. After giving the first dose and teaching the patient about the drug, which statement by the patient indicates that teaching has been effective? a. "I will be sure to take the medication with food." b. "I will need to eat more potassium-rich foods in my diet." c. "I will call for help when I need to get up to use the bathroom." d. "I will expect to feel more short of breath for the next few days."

A patient with rheumatoid arthritis (RA) complains to the clinic nurse about having chronically dry eyes. Which action by the nurse is appropriate? a. Ask the HCP about discontinuing methotrexate b. Remind the patient that RA is a chronic health condition. c. Suggest the patient use over-the-counter (OTC) artificial tears. d. Teach the patient about adverse effects of the RA medications.

During the physical assessment of the patient with early to moderate RA, what should the nurse expect to find? a. hepatomegaly b. Heberden's nodes c. spindle-shaped fingers d. crepitus on joint movement

IV sodium nitroprusside is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate down if the patient develops a. ventricular ectopy. b. a dry, hacking cough. c. a systolic BP below 90 mm Hg. d. a heart rate below 50 beats/min.

The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse take if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a stat chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading.

The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A patient a. with a blood glucose of 350 mg/dL b. who has been on anticoagulants for 10 days c. with a hemoglobin of 8.5 g/dL d. with a heart rate of 100 beats/min and blood pressure of 100/60

The nurse is delivering teaching to a female patient newly diagnosed with systemic lupus erythematosus (SLE). Which statement demonstrates the patient's need for further teaching about the disease? a. "I'll try my best to stay out of the sun this summer." b. "I know that I have a high chance of getting arthritis." c. "I'm hoping surgery will be an option for me in the future." d. "I understand I'm going to be vulnerable to getting infections."

The nurse is presenting a class on chest tubes. Which statement describes a tension pneumothorax? 1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Appropriate instructions for the patient include a. limit dietary sources of potassium. b. take the hydrochlorothiazide before bedtime. c. notify the health care provider if nausea develops. d. take the digoxin if the pulse is below 60 beats/min.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung. Which information should the nurse include about the patient's postoperative care? a. Positioning on the right side b. Bed rest for the first 24 hours c. Frequent use of an incentive spirometer d. Chest tube placement with continuous drainage

The nurse tells the patient with RA that which exercise is one of the most effective methods of aerobic exercise? a. Ballet dancing b. Casual walking c. Aquatic exercises d. Low impact aerobic exercises

The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that a. she will take furosemide (Lasix) every day at bedtime. b. the nitroglycerin patch is to be used when chest pain develops. c. she will call the clinic if her weight goes up 3 pounds in 1 week. d. an additional pillow can help her sleep if she is short of breath at night.

What is an ominous sign of advanced SLE disease? a. Proteinuria from early glomerulonephritis b. Anemia from antibodies against blood cells c. Dysrhythmias from fibrosis of the atrioventricular node d. Cognitive dysfunction from immune complex deposit in the brain

When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate. The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." The most appropriate response by the nurse is a. "You have the right to refuse to take the methotrexate." b. "Methotrexate is less expensive than some of the newer drugs." c. "It is important to start methotrexate early to decrease the extent of joint damage." d. "Methotrexate is effective and has fewer side effects than some of the other drugs."

Which laboratory result is important to communicate to the health care provider for a patient who is taking methotrexate to treat rheumatoid arthritis (RA)? a. Rheumatoid factor is positive. b. Fasting blood glucose is 90 mg/dL. c. The white blood cell (WBC) count is 1500/μL. d. The erythrocyte sedimentation rate is elevated.

While assessing a 68-yr-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates a. decreased fluid volume. b. jugular vein atherosclerosis. c. increased right atrial pressure. d. incompetent jugular vein valves.

A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk? a. The infant is becoming more active. b. There is an increase in intake of breast milk or formula. c. The infant is unable to maintain an adequate iron intake. d. A depletion of fetal hemoglobin occurs.

A patient who has just been admitted with pulmonary edema is scheduled to receive the following medications. Which medication should the nurse question before giving? a. captopril 25 mg b. furosemide (Lasix) 60 mg c. digoxin (Lanoxin) 0.125 mg d. carvedilol (Coreg) 3.125 mg

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority? a. Hyperthermia related to infectious illness b. Impaired transfer ability related to weakness c. Ineffective airway clearance related to thick secretions d. Impaired gas exchange related to respiratory congestion

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care? a. Schedule a sweat chloride test. b. Arrange for a hospice nurse visit. c. Place the patient on a low-sodium diet. d. Perform chest physiotherapy every 4 hours.

After change-of-shift report, which patient should the nurse assess first? a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

After teaching a patient with RA to use heat and cold therapy to relieve symptoms, the nurse determines that teaching has been effective when what is said by the patient? a. Heat treatments should not be used if muscle spasms are present b. Cold applications can be applied for 15-20 minutes to relieve joint stiffness c. I should use heat applications for 20 minutes to relieve symptoms of an acute flare d. When my joints are painful, I can use a bag of frozen corn for 10-15 minutes to relieve the pain

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Milk the chest tube gently to remove any clots. b. Clamp the chest tube momentarily to check for the origin of the air leak. c. Assist the patient to deep breathe, cough, and use the incentive spirometer. d. Set up the patient controlled analgesia (PCA) and administer the loading dose of morphine.

An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? a. 2+ bilateral pedal edema b. Heart rate of 56 beats/min c. Complaints of increased fatigue d. Blood pressure (BP) of 88/42 mm Hg

Following an acute myocardial infarction, a previously healthy 63-yr-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. β-Adrenergic blockers. b. calcium channel blockers. c. digitalis and potassium therapy regimens. d. angiotensin-converting enzyme (ACE) inhibitors.

In teaching a patient with systemic lupus erythematosus about the disorder, the nurse knows the pathophysiology includes a. circulating immune complexes formed from IgG autoantibodies reacting with IgG b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles d. the production of a variety of autoantibodies directed against components of the cell nucleus

Laboratory findings that the nurse would expect to be present in the patient with RA include a. Polycythemia b. Increased IgG c. Decreased WBC d. anti-citrullinated protein antibody

The client has a right-sided chest tube. As the client is getting out of the bed it is acci- dentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

The glucose levels indicate that the patient has developed CF-related diabetes, and insulin therapy is required. Because the etiology of diabetes in CF is inadequate insulin production, oral hypoglycemic agents are not effective. The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? a. Supine with the head of the bed elevated 30 degrees b. In a high-Fowler's position with the left arm extended c. On the right side with the left arm extended above the head d. Sitting upright with the arms supported on an over bed table

The home health nurse is interviewing an older patient with a history of RA who reports "feeling pretty good, except for the pain and stiffness in my joints when I first get out of bed." Which member of the health care team would be notified to aid in the patient's pain? a. HCP to review the dosage and frequency of pain medication b. physical therapist for evaluation of function and possible exercise therapy c. social worker to locate community resources for complementary therapy d. home health aide to help patient with a warm shower in the morning

The home health nurse is making a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates more patient teaching is needed? a. The patient takes a 2-hour nap each day. b. The patient has been taking 16 aspirins each day. c. The patient sits on a stool while preparing meals. d. The patient sleeps with two pillows under the head.

The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement? a. "I will make an appointment to see the doctor every year." b. "I will stop taking the prednisone if I experience a dry cough." c. "I will not worry if I feel a little short of breath with exercise." d. "I will call the health care provider right away if I develop a fever."

The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? a. Weight loss of 2 lb in 24 hours b. Hourly urine output greater than 60 mL c. Reduction in patient complaints of chest pain d. Reduced dyspnea with the head of bed at 30 degrees

The nurse obtains a history from a 46-year-old woman with RA. The nurse should follow up on which patient statement? a. "I perform range of motion exercises at least twice a day." b. "I use a heating pad for 20 minutes to reduce morning stiffness." c. "I take a 20-minute nap in the afternoon even if I sleep 9 hours at night." d. "I restrict fluids to prevent edema when taking methotrexate."

The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus. Which action should the nurse take next? a. Palpate the anterior chest and observe for barrel chest. b. Encourage the patient to turn, cough, and deep breathe. c. Review the chest x-ray report for evidence of pneumonia. d. Auscultate anterior and posterior breath sounds bilaterally.

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."

The team leader is talking to Ms. R (RA) about discharge plans and follow-up appointments. She begins to cry and says, "I was so active and athletic when I was younger." What is the most therapeutic response? a. Your should will get progressively better with time and patience. Don't cry. b. I can see that you are really upset. Is your should hurting a lot right now? c. I know what you mean. I used to be able to do a lot more when I was younger, too. d. It is difficult to deal with changes. What types of activities did you used to do?

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? a. Emergency pericardiocentesis b. Stabilization of the chest wall with tape c. Administration of an inhaled bronchodilator d. Insertion of a chest tube with a chest drainage system

When caring for the patient with CREST syndrome (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, telangiectasia) associated with scleroderma, what should the nurse teach the patient to do? a. maintain a fluid intake of at least 3000 mL/day b. avoid exposure to the sun or other ultraviolet light c. monitor and keep of a log of daily BP d. protect the hands and feet from cold exposure and injury

Which clinical management prevention concept would the nurse identify as representative of secondary prevention? a. Decreasing venous stasis and risk for pulmonary emboli b. Implementation of strict hand washing routines c. Maintaining current vaccination schedules d. Prevention of pneumonia in patients with chronic lung disease

Which topic will the nurse plan to include in discharge teaching for a patient with heart failure with reduced ejection fraction (HFrEF)? a. Need to begin an aerobic exercise program several times weekly b. Use of salt substitutes to replace table salt when cooking and at the table c. Importance of making an annual appointment with the health care provider d. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors

While admitting an 82-yr-old patient with acute decompensated heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the patient's discharge the nurse will facilitate a a. plan for around-the-clock care. b. consultation with a psychologist. c. transfer to a long-term care facility. d. referral to a home health care agency.

what does the R stand for in crest?

Raynaud's phenomenon (poor perfusion)

A kidney transplant recipient has had fever, chills, and dysuria over the past 2 days. What is the first action that the nurse should take? a. Assess temperature and initiate workup to rule out infection. b. Reassure the patient that this is common after transplantation. c. Provide warm covers to the patient and give 1 gram oral acetaminophen. d. Notify the nephrologist that the patient has manifestations of acute rejection.

A nursing student who is researching a medication at the nurses' station asks the registered nurse (RN) what the function of an alpha-adrenergic receptor is, and where the receptors are primarily found. The RN educates the nursing student. Which statement by the nursing student indicates that teaching has been effective? a. "The peripheral arteries and veins; when stimulated they cause vasoconstriction." b. "Arterial and bronchial walls; when stimulated they cause vasodilation and bronchodilation." c. "The heart; when stimulated it causes an increase in heart rate, atrioventricular node conduction, and contractility." d. "Several tissues; when stimulated they cause contraction of smooth muscle, inhibition of lipolysis, and promotion of platelet aggregation."

A patient has been receiving high-dose corticosteroids and broad-spectrum antibiotics for treatment of an infection after a traumatic injury. The nurse plans care for the patient knowing that the patient is most susceptible to a. candidiasis. b. cryptococcosis. c. histoplasmosis. d. coccidioidomycosis.

A patient is admitted to the hospital with chronic kidney disease. The nurse understands that this condition is characterized by a. progressive irreversible destruction of the kidneys. b. a rapid decrease in urine output with an elevated BUN. c. an increasing creatinine clearance with a decrease in urine output. d. prostration, somnolence, and confusion with coma and imminent death.

A patient who has bronchiectasis asks the nurse, "What conditions would warrant a call to the clinic?" a. Blood clots in the sputum b. Sticky sputum on a hot day c. Increased shortness of breath after eating a large meal d. Production of large amounts of sputum on a daily basis

A patient with ARDS is receiving O2 by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. which action does the nurse anticipate the HCP will prescribe? a. perform endotracheal intubation and initiate mechanical ventilation b. immediately begin CPAP via patients nose and mouth c. administer furosemide 100mg IV push immediately d. call RRT

A priority nursing intervention for a patient who has just undergone a chemical pleurodesis for recurrent pleural effusion is a. giving ordered analgesia. b. monitoring chest tube drainage. c. sending pleural fluid for laboratory analysis. d. monitoring the patient's level of consciousness.

An ESRD patient receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In helping the patient decide about treatment, the nurse informs the patient that a. successful transplantation usually provides better quality of life than that offered by dialysis. b. if rejection of the transplanted kidney occurs, no further treatment for the renal failure is available. c. hemodialysis replaces the normal functions of the kidneys, and patients do not have to live with the continual fear of rejection. d. the immunosuppressive therapy after transplantation makes the person ineligible to receive other treatments if the kidney fails.

The UAP is assisting with feeding for a patient with severe end stage COPD. which instructions will the nurse provide the UAP? a. encourage patient to eat foods that are high in calories and protein b. feed patient as quickly as possible to prevent early satiety c. offer lots of fluids between bites of food d. try to get the patient to eat everything on the tray

The UAP tells the nurse that a patient who is receiving oxygen at a flow rate of 6L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the UAP to improve the patient's comfort for this problem?- a. humidify oxygen b. use simple face mask instead of nasal cannula c. provide patient with an extra pillow d. have patient sit up in a chair at the bedside

The critical care charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence? a. 68yo with history of smoking and emphysema b. 57yo who experienced cardiac arrest c. 49yo postop patient who had a colectomy d. 29yo recovering from flail chest

The key anatomic landmark that separates the upper respiratory tract from the lower respiratory tract is the a. carina. b. larynx. c. trachea. d. epiglottis.

The nurse is admitting a patient for whom a diagnosis of PE must be ruled out. The patients history and assessment reveal all of these findings. Which finding supports the diagnosis of PE? a. patient recently in a MVC b. patient participated in an aerobic program for 6 months c. patient gave birth to her youngest 1 year ago d. patient on bedrest for 6 hours after diagnostic procedure

The nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define and document this finding? a. 1+ b. 2+ c. 3+ d. 4+

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? a. Protecting the client from infection b. Providing emotional support to decrease fear c. encouraging discussion about lifestyle changes d. Identifying factors that decreased the immune function

The nurse is caring for a client receiving an albuterol/ipratropium nebulized breathing treatment. Which report from the client should the nurse note as an expected side effect of this combination medication? a. I feel like my heart is racing b. I feel more bloated than usual c. My eyes have been watering d. I haven't had a bm in 4 days

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse would include which intervention in the plan? a. Maintain activity level as prescribed. b. Maintain the affected leg in a dependent position. c. Administer an opioid analgesic every 4 hours around the clock. d. Apply cool packs to the affected leg for 20 minutes every 4 hours.

The nurse is monitoring the function of a client's chest tube that is attached to a drainage system. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring? a. tidaling is present b. there is a leak in the system c. client has residual pneumothorax d. suction should be added to the system

The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test? a. Thoracentesis b. Bronchoscopy c. Pulmonary angiography d. Sputum culture and sensitivity

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? a. "I should take hot baths because they are relaxing." b. "I should sit whenever possible to conserve my energy." c. "I should avoid long periods of rest because it causes joint stiffness." d. "I should do some exercises, such as walking, when I am not fatigued."

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? a. I should take hot baths because they are relaxing b. I should sit wherever possible to conserve my energy c. I should avoid long periods of rest because it causes joint stiffness d. I should do some exercises, such as walking, when I am not fatigued

When caring for a patient with acute bronchitis, the nurse will prioritize interventions by a. auscultating lung sounds. b. encouraging fluid restriction. c. administering antibiotic therapy. d. teaching the patient to avoid cough suppressants.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? a. The client who is taking diuretics b.The client with hyperaldosteronism c.The client with Cushing's syndrome d.The client who is taking corticosteroids

a 2yo client with cystic fibrosis is confined to bed and is not allowed to go to the playroom. which of the following is an appropriate toy would the nurse select for the client a. pounding board and hammer b. arranging stickers in the album c. musical automobile d. puzzle

a client appears dyspneic, but the oxygen saturation is 97%. what action by the nurse is best? a. assess for other manifestations of hypoxia b. change sensor on pulse oximeter c. obtain a new oximeter from central supply d. tell client to take slow, deep breaths

an 8yo client with cystic fibrosis is admitted to the hospital and will undergo a chest physiotherapy treatment. the therapy should be properly coordinated by the nurse with the respiratory therapy department so that treatments occur during: a. between meals b. after meals c. after medication d. around the child's play schedule

betty is a 9yo girl diagnosed with cystic fibrous. which of the following must the nurse keep in mind when developing a care plan for the child? a. pulmonary secretions are abnormally thick b. elevated levels of potassium are found in sweat c. CF is an autosomal dominant hereditary disorder d. obstruction of the endocrine glands occurs

the nurse is assisting a provider with the removal of a chest tube. which of the following nursing interventions is the priority once the tube is removed from the chest? a. apply occlusive dressing b. assess lung sounds c. clean wound with soap and water d. culture insertion site

which stage of RA includes thickened synovial membranes and inflammation? a. synovitis b. pannus c. fibrous ankylosis

what are common risk factors for SLE? select all that apply a. women b. race/ethnicity c. low socioeconomic status d. history of chronic illness

a, b

Nutritional support and management are essential across the entire continuum of chronic kidney disease. Which statements are true related to nutritional therapy? (select all that apply) a. Sodium and salt may be restricted in someone with advanced CKD. b. Fluid is not usually restricted for patients receiving peritoneal dialysis. c. Decreased fluid intake and a low-potassium diet are part of the diet for a patient receiving hemodialysis. d. Decreased fluid intake and a low-potassium diet are part of the diet for a patient receiving peritoneal dialysis. e. Decreased fluid intake and a diet in protein-rich foods are part of a diet for a patient receiving hemodialysis.

a, b, c

A student nurse asks the RN what can be measured by arterial blood gas (ABG). The RN tells the student that the ABG can measure (select all that apply) a. acid-base balance. b. oxygenation status. c. acidity of the blood. d. bicarbonate (HCO3-). e. compliance and resistance.

a, b, c, d

Defense mechanisms that help protect the lung from inhaled particles and microorganisms include the (select all that apply) a. cough reflex. b. mucociliary escalator. c. alveolar macrophages. d. reflex bronchoconstriction. e. alveolar capillary membrane.

a, b, c, d

A patient with a PE is receiving anticoagulation with IV heparin. What instructions would the nurse give the UAP who will help the patient with ADLs? Select all that apply. a. use lift sheet when moving and positioning the patient in bed b. use electric razor c. use soft-bristled brush or tooth sponge d. use rectal thermometer to obtain more accurate body temperature e. be sure footwear has firm sole when ambulating f. assess patient for s/s of bleeding

a, b, c, e

which medications are used to treat autoimmune diseases? select all that apply a. DMARDS b. biologics c. corticosteroids d. antipyretics e. immunosuppressant f. opioids

a, b, c, e

An experienced LPN/LVN, under the supervision of the team leader RN, is assigned to provide nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN? select all that apply a. auscultating breath sounds b. administering mediations via metered dose inhaler (MDI) c. completing in-depth admission assessment d. checking oxygen saturation using pulse oximetry e. developing the nursing care plan f. evaluating the patients technique for MDIs

a, b, d

Patients with chronic kidney disease have an increased incidence of cardiovascular disease related to (select all that apply) a. hypertension. b. vascular calcifications. c. a genetic predisposition. d. hyperinsulinemia causing dyslipidemia. e. increased high-density lipoprotein levels.

a, b, d

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply. a. Sitting up and leaning on a table b. Standing and leaning against a wall c. Lying supine with the feet elevated d. Sitting up with the elbows resting on knees e. Lying on the back in a low-Fowler's position

a, b, d

Nurses can screen patients at risk for developing chronic kidney disease. Those considered to be at increased risk include (select all that apply) a. older black patients. b. patients more than 60 years old. c. those with a history of pancreatitis. d. those with a history of hypertension. e. those with a history of type 2 diabetes.

a, b, d, e

Which interventions for a patient with a pulmonary embolus would the RN assign to the LPN/LVN on the patient care team? a. evaluating patients reports of chest pain b. monitoring lab values for changes in oxygenation c. assessing for symptoms of respiratory failure d. auscultating lungs for crackles

Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply. a. Obtain an intravenous (IV) infusion pump. b. Monitor urine output during administration. c. Prepare the medication for bolus administration. d. Monitor the IV site for signs of infiltration or phlebitis. e. Ensure that the medication is diluted in the appropriate volume of fluid. f. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

a, b, d, e, f

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. a. nausea b. confusion c. bradypnea d. tachycardia e. hyperkalemia f. lightheadedness

a, b, d, f

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse should recognize that which are early clinical manifestations of this disorder? Select all that apply. a. fatigue b. anorexia c. high fever d. weight loss e. generalized weakness

a, b, e

Which patients have the greatest risk for aspiration pneumonia? (select all that apply) a. Patient with seizures b. Patient with head injury c. Patient who had thoracic surgery d. Patient who had a myocardial infarction e. Patient who is receiving nasogastric tube feeding

a, b, e

what are common risk factors for RA? select all that apply a. women b. history of cancer c. age between 40-50 d. older adults e. immunosuppressed

a, c

Which treatments would the nurse expect to implement in the management plan of a patient with cystic fibrosis? (select all that apply) a. Sperm banking b. IV corticosteroids on a chronic basis c. Airway clearance techniques (e.g., Acapella) d. GoLYTELY given as needed for severe constipation e. Inhaled tobramycin to combat Pseudomonas infection

a, c, d, e

A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? a. Maintain bed rest as much as possible. b. Administer capsaicin cream as prescribed for pain. c. Advise the client to remain supine for 1 to 2 hours after meals. d. Keep the room temperature warm during the day and cool at night.

A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? a. Maintain bed rest as much as possible. b. Administer corticosteroids as prescribed for inflammation. c. Advise the client to remain supine for 1 to 2 hours after meals. d. Keep the room temperature warm during the day and cool at night.

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? a. serous b. bloody c. serosanguineous d. bloody, with frequent small clots

A primary health care provider (PHCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the PHCP's use? a. telfa dressing and neosporin ointment b. petrolatum gauze and sterile 4x4 c. benzoin spray and hydrocolloid dressing d. sterile 4x4, neosporin, and tape

The RN is teaching a UAP to check O2 sats by pulse ox. What will the nurse be sure to tell the UAP about patients with darker skin? a. be aware that patients with darker skin usually show a 3-5% higher oxygen saturation compared with light-skinned b. usually dark-skinned patients show 3-5% lower oxygen saturation than light-skinned c. dark skinned patient may get more accurate results by messing pulse oximetry on patient toes d. more accurate results may result from continuous pulse oximetry monitoring than spot checking with darker skinned patients

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? a. low respiratory rate b. diminished breath sounds c. presence of barrel chest d. sucking sound at site of injury

The high pressure alarm on a patient ventilator goes off. when then nurse enter the room to assess the patient, who has ARDS, the O2 sat monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first? a. reassure patient the vent will do the work of breathing for him b. manually ventilate the patient while assess for possible reasons for the high-pressure alarm c. increase fraction of inspired oxygen on vent to 100% in preparation for trach suctioning d. insert oral airway to prevent the patient form biting on the tube

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? a. Do nothing because this is an expected finding. b. Check for an air leak because the bubbling should be intermittent. c. Increase the suction pressure so that the bubbling becomes vigorous. d. Clamp the chest tube and notify the primary health care provider immediately.

The nurse determines that a client requires further teaching after permanent pacemaker insertion if which statement is made? a. I'll need to call my cardiologist if I feel tired or dizzy b. My pulse should be less than what my pacemaker is set at c. I'll have to avoid carrying the grocery bags into the house for the next six weeks d. It's safe to use my microwave as long as its properly grounded and well shielded

The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. which action should the nurse delegate to an experienced UAP? a. assess respiratory status Q4h b. take vital signs Q4h c. check vent settings to make sure they are as prescribed d. observing whether the patients tube needs suctioning Q2h

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? a. anxiety level of client and family b. activation status and settings of device c. presence of medicalert card for client to carry d. knowledge of restrictions on postdischarge physical activity

Which respiratory assessment finding does the nurse interpret as abnormal? a. Inspiratory chest expansion of 1 inch b. Symmetric chest expansion and contraction c. Resonance (to percussion) over the lung bases d. Bronchial breath sounds in the lower lung fields

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving O2 at a flow rate of 5L/min by nasal cannula. Which finding concerns the nurse immediately? a. fine bibasilar crackles b. respiratory rate of 8 breaths/min c. the patient sitting up and leaning over the nightstand d. large barrel chest

The nurse is monitoring a client with hypertension who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication? a. Report of infrequent insomnia b. Development of expiratory wheezes c. A baseline blood pressure of 150/80 mm Hg after 2 doses of the medication d. A baseline resting heart rate of 88 beats per minute followed by a resting heart rate of 72 beats per minute after 2 doses of the medication

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? a. check for air leak b. document findings c. notify PCP d. change chest tube drainage system

The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery. Which statement made by the client indicates a need for further teaching? a. "I should avoid heavy lifting for at least 4 to 6 weeks." b. "I should remove the chest tube site dressing as soon as I get home." c. "If I have any difficulty breathing, I should call the primary health care provider." d. "If I note any signs of infection, I should contact the primary health care provider."

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which is an early clinical manifestation of RA? a. anemia b. anorexia c. amenorrhea d. night sweats

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? a. chest tube drainage of 10-15ml/hr b. continuous bubbling in the water-seal chamber c. reports of pain at the chest tube site d. chest tube dressing dated yesterday

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mmol/L), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? a.Metabolic acidosis, compensated b.Respiratory alkalosis, compensated c. Metabolic alkalosis, uncompensated d. Respiratory acidosis, uncompensated

To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for a. dyspnea and hypotension. b. apprehension and restlessness. c. cyanosis and cool, clammy skin. d. increased urine output and diaphoresis.

When auscultating the chest of an older patient in mild respiratory distress, it is best to a. begin listening at the apices. b. begin listening at the lung bases. c. begin listening on the anterior chest. d. Ask the patient to breathe through the nose with the mouth closed.

When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes a. maintaining the patient on bed rest. b. using intermittent pneumatic compression devices. c. encouraging the patient to cough and deep breathe. d. teaching the patient how to use the incentive spirometer.

a client is on IV heparin to treat a PE. the clients most recent PTT was 25 seconds. what order should the nurse anticipate? a. decrease heparin rate b. increase heparin rate c. no change to rate d. stop heparin and start warfarin

a nurse answers a call light and finds a client anxious, sob, reporting chest pain, and having a BP of 88/52 on cardiac monitor. what action by the nurse takes priority? a. assess lung sounds b. notify RRT c. provide reassurance to client d. take full set of vitals

a nurse is caring for four clients on IV heparin therapy. which lab value possibly indicates that a serious side effect has occurred? a. hemoglobin 14.2 b. platelets 82,000 c. RBC 4.8 d. WBC 8.7

which stage of RA includes cartilage destruction a. synovitis b. pannus c. fibrous ankylosis

During the oliguric phase of AKI, the nurse monitors the patient for (select all that apply) a. hypotension. b. ECG changes. c. hypernatremia. d. pulmonary edema. e. urine with high specific gravity.

b, d

The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nursed to the UAP? Select all that apply. a. access puncture site and dressing for leakage b. check vitals every 15 minutes for one hour c. auscultate for absent or reduced lung sounds d. remind the patient to take deep breaths e. take specimens to laboratory f. teach patient symptoms of pneumothorax

b, d, e

When assessing subjective data related to the respiratory health of a patient with emphysema, the nurse asks about (select all that apply) a. date of last chest x-ray. b. dyspnea during rest or exercise. c. pulmonary function test results. d. ability to sleep through the entire night. e. prescription and over-the-counter medication.

b, d, e

what is the number one sign of sle?

butterfly rash

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? a. hot, flushed feeling b. sudden chills and fever c. chest pain that occurs suddenly d. dyspnea when deep breaths are taken

A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's record, the nurse should expect to note documentation of which characteristic sign of SLE? a. fever b. fatigue c. skin lesions d. elevated RBC

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? a. cyanosis b. hypotension c. paradoxical chest movement d. dyspnea, especially on exhalation

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? a. bradycardia and hyperactivity b. decreased respiratory rate and depth c. headache, restlessness, and confusion d. bradypnea, dizziness, paresthesia

A nursing student is developing a plan of care for a client with a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student? a. position in semi-fowlers b. add water to suction chamber as it evaporates c. instruct client to avoid coughing and deep breathing d. tape connection sites between chest tube and drainage system

If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances? a. Hyperkalemia and hyponatremia b. Hyperkalemia and hypernatremia c. Hypokalemia and hyponatremia d. Hypokalemia and hypernatremia

The nurse can best determine adequate arterial oxygenation of the blood by assessing a. heart rate. b. hemoglobin level. c. arterial oxygen partial pressure. d. arterial carbon dioxide partial pressure.

The nurse employed in a cardiac unit determines that which client is the least likely to have an implanted cardioverter-defibrillator (ICD) inserted? a. syncopal episodes related to ventricular tachycardia b. ventricular dysrhythmias despite medication therapy c. episode of cardiac arrest related to MI d. 3 episodes of cardiac arrest unrelated to MI

The nurse has just finished assisting the HCP with a thoracentesis removed 1800ml of fluid. Which patient assessment information is most important to report to the HCP? a. patient starts crying and says she can't go on with treatment much longer b. patient reports sharp, stabbing chest pain with every breath c. BP is 100/48 and HR is 102 d. dressing at thoracentesis site has 1cm of bloody drainage

The nurse identifies a flail chest in a trauma patient when a. multiple rib fractures are determined by x-ray. b. a tracheal deviation to the unaffected side is present. c. paradoxical chest movement occurs during respiration. d. there is decreased movement of the involved chest wall.

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? a. restricting fluids b. placing pillow under knees c. encouraging active ROM d. applying heating pad to lower extremities

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? a. muscle twitches b. decreased urinary output c. hyperactive bowel sounds d. increased specific gravity

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? a. weight loss and dry skin b. flat neck and hand veins and decreased urinary output c. increase in blood pressure and respirations d. weakness and decreased CVP

The nurse is caring for a patient newly admitted with heart failure secondary to dilated cardiomyopathy. Which intervention would be a priority? a. Encourage caregivers to learn CPR. b. Consider a consultation with hospice for palliative care. c. Monitor the patient's response to prescribed medications. d. Arrange for the patient to enter a cardiac rehabilitation program.

The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? a. administer ordered antibiotics as scheduled b. hyper oxygenate before suctioning c. maintain HOB 30-45 degrees d. suction airway when coarse crackles are audible

The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema? a. pain with deep breathing b. increased chest tube drainage c. lung crackles in remaining lung d. respiratory rate of 20 breaths/min

The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the UAP? a. teaching patient about importance of adequate fluid intake and hydration b. assisting patient to sitting position with neck flexed, shoulders relaxed and knees flexed c. reminding the patient to use an incentive spirometer every 1-2 hours d. encoring the patient to take a deep breath, hold for 2 sec, and then cough two or three times in succession

The nurse is making a home visit to a 50yo patient who was recently hospitalized with right leg DVT and a PE. The patients only medication is enoxaparin SQ. Which assessment information will the nurse need to communicate to the HCP? a. patient says her right leg aches all night b. right calf is warm to the touch and larger than left c. patient unable to remember husbands first name d. multiple ecchymotic areas on patients abdomen

The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess for that also is indicative of SLE? a. ascites b. emboli c. facial rash d. two hemoglobin S genes

The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? a. Use nail polish to protect the nail beds from injury. b. Wear gloves for all activities involving the use of both hands. c. Stop smoking because it causes cutaneous blood vessel spasm. d. Always wear warm clothing, even in warm climates, to prevent vasoconstriction.

The nurse is preparing to care for a client with immunodeficiency. The nurse should plan to address which problem as the priority? a. anxiety b. fatigue c. risk for infection d. need for social isolation

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit? a. dilate major bronchi b. increase surfactant production c. maintain inflation of alveoli d. enhance ciliary action in tracheobronchial tree

The nurse is the preceptor for an RN who is undergoing orientation to the ICU. the RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately? a. assess for bilateral breath sounds and symmetrical chest movement b. use end-tidal carbon dioxide detector to confirm ET position c. mark 1 cm from where tube touches incisor tooth or nares d. orders chest xray to verify placement

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 mm Hg, PaO2 of 80 mm Hg, and HCO3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

The nurse should report which assessment finding to the primary health care provider (PHCP) before initiating thrombolytic therapy in a client with pulmonary embolism? a. adventitious breath sounds b. temperature of 99.4 orally c. BP of 198/110 d. respiratory rate of 28/min

a nurse is preparing a patient for a thoracentesis. which is the proper positioning of this patient? a. HOB 45 degrees with patient laying on unaffected side b. HOB flat with patient laying on affected side c. sitting up, leaning over bedside table with feet supported on a stool d. prone with both arms extended above the head

a nurse receives report on the following four patients who all have chest tubes placed. which patient is the priority to see first? a. the patient with tidaling in the drainage tubing b. patient whose drainage system is standing on the floor c. patient who has constant bubbling in drainage chamber d. patient with suction pressure at -20cmH2O

a patient with a suspected empyema has a thoracentesis, and pleural fluid has been sent to the lab for examination. which of the following constituents of the pleural fluid would best support a diagnosis of empyema? a. epithelial cells b. plasma proteins c. leukocytes d. erythrocytes

how long is the onset of scleroderma? a. years b. slow c. fast d. unknown

the family of a patient with a pleural effusion is concerned because the patient isn't "coughing up" any fluid. the nurse understands that this is an expected finding because a. pressure of the fluid is restricting the airway b. fluid collected is excreted through circulatory system c. fluid collection is outside of the airways and alveoli d. effusion has most likely resolved

the patient is undergoing a thoracentesis for a PE. after the procedure, the healthcare provider will monitor the patient for which of the following possible complications of the procedure? a. respiratory acidosis b. pulmonary fibrosis c. pneumothorax d. coagulopathy

which stage of RA includes fibrous tissue that evolves into scar tissue? a. synovitis b. pannus c. fibrous ankylosis

The home care nurse provides instructions to a client with systemic lupus erythematosus (SLE) about home care measures. Which statements by the client indicate the need for further instruction? Select all that apply. a. "I need to sit whenever possible." b. "I need to be sure to eat a balanced diet." c. "I need to take a hot bath every evening." d. "I need to rest for long periods of time every day." e. "I should engage in moderate low-impact exercise when I am not tired

c, d

During the respiratory assessment of an older adult, the nurse would expect to find (select all that apply) a. a vigorous reflex cough. b. increased chest expansion. c. increased residual volume. d. decreased lung sounds at base of lungs. e. increased anteroposterior (AP) chest diameter.

c, d, e

To assess the patency of a newly placed arteriovenous graft for dialysis, the nurse should (select all that apply) a. monitor the BP in the affected arm. b. irrigate the graft daily with low-dose heparin. c. palpate the area of the graft to feel a normal thrill. d. listen with a stethoscope over the graft to detect a bruit. e. assess the pulses and neurovascular status distal to the graft.

c, d, e

The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. a. Excessive bubbling in the water seal chamber b. Vigorous bubbling in the suction control chamber c. Drainage system maintained below the client's chest d. 50 mL of drainage in the drainage collection chamber e. Occlusive dressing in place over the chest tube insertion site f. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

c, d, e, f

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. a. ST depression b. prominent U wave c. tall peaked T waves d. prolonged ST segment e. widened QRS complexes

c, e

a client has a pulmonary embolism and is started on oxygen. the student nurse asks why the clients oxygen saturation has not significantly improved. what response by the nurse is best? a. breathing so rapidly interferes with oxygenation b. the client may have respiratory distress syndrome c. the blot clot interferes with perfusion in the lungs d. client needs immediate intubation and mechanical ventilation

what does the C stand for in crest

calcinosis cutis (bumps)

A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which disorder? a. hyperthyroidism b. pernicious anemia c. cardiopulmonary disorders d. systemic lupus erythematosus

A client seen in an ambulatory clinic has a facial rash that is present on both cheeks and across the bridge of the nose. The nurse interprets that this finding is consistent with manifestations of which disorder? a. hyperthyroidism b. pernicious anemia c. cardiopulmonary disorders d. systemic lupus erythematosus

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mmol/L), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? a. metabolic acidosis with comp b. respiratory acidosis with comp c. metabolic acidosis without comp d. respiratory acidosis without comp

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? a. decreased pH, increased PaCO2 b. increased pH, decreased PaCO2 c. decreased pH, decreased HCO3 d. increased pH, increased HCO3

A client with pulmonary edema has been receiving diuretic therapy. The client has a prescription for additional furosemide in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin, which laboratory result should the nurse review as the priority? a. sodium b. digoxin c. creatinine d. potassium

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? a. "I should notify my cardiologist if my feet or legs start to swell." b."I am supposed to report to my cardiologist if my pulse rate decreases below 60." c."Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." d."My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

A complete blood cell (CBC) count is performed in a client with systemic lupus erythematosus (SLE). The nurse would suspect that which finding will be noted in the client with SLE? a. decreased platelets only b. increased RBC c. increased WBC d. decreased number of all cell types

A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse suspects that which finding will be reported with this blood test? a. increased neutrophils b. increased RBC count c. increased WBC count d. decreased number of all cell types

A patient asks, "How does air get into my lungs?" The nurse bases her answer on knowledge that air moves into the lungs because of a. positive intrathoracic pressure. b. contraction of the accessory abdominal muscles. c. stimulation of the respiratory muscles by the chemoreceptors. d. a decrease in intrathoracic pressure from an increase in thoracic cavity size.

A rheumatoid factor assay is performed in a client with a suspected diagnosis of rheumatoid arthritis (RA). Which laboratory result should the nurse anticipate? a. presence of inflammation b. presence of infection in the body c. presence of antigens of immmunoglobulin A (IgA) d. presence of unusual antibodies of the IgG and IgM

A test for the presence of rheumatoid factor is performed in a client with a diagnosis of rheumatoid arthritis (RA). What result should the nurse anticipate in the presence of this disease? a. neutropenia b. hyperglycemia c. antigens of immunoglobulin A (IgA) d. unusual antibodies of the IgG and IgM

After change of shit, the nurse is assigned to care for the following patients. Which patient should the nurse assess first? a. 68yo on vent for whom a sterile sputum specimen must be sent to lab b. 57yo with COPD and pulse ox reading from previous shift of 90% c. 72yo with pneumonia who needs to be started on IV antibiotics d. 51yo with asthma who reports SOB after using bronchodilator inhaler

After extubation of a patient, which finding would the nurse report to the HCP immediately? a. respiratory rate of 25/min b. patient has difficulty speaking c. oxygen saturation of 93% d. crowing noise during inspiration

After the respiratory therapist performs suctioning on a patient who is intubated, the UAP measures vital signs for the patient. Which vital sign value should the UAP report to the RN immediately? a. Heart rate of 98 beats/min b. Respiratory rate of 24 breaths/min c. Blood pressure of 168/90 mm Hg d. Tympanic temperature of 101.4° F (38.6° C)

An appropriate nursing intervention to assist a patient with pneumonia manage thick secretions and fatigue would be to a. perform postural drainage every hour. b. provide analgesics as ordered to promote patient comfort. c. administer O2 as prescribed to maintain optimal O2 levels. d. teach the patient how to cough effectively and expectorate secretions.

RIFLE defines the first 3 stages of AKI based on changes in a. blood pressure and urine osmolality. b. fractional excretion of urinary sodium. c. estimation of GFR with the MDRD equation. d. serum creatinine or urine output from baseline.

The nurse is assisting a primary health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? a. stay very still b. exhale very quickly c. inhale and exhale quickly d. perform valsalva maneuver

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? a. sitting up in bed b. side-lying in bed c. sitting up in recliner d. sitting up and leaning on overbed table

The nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. How should the nurse assess for this disease? a. checking for rash on digits b. observing softening of nails or nail beds c. palpating for a rapid or irregular peripheral pulse d. palpating for diminished or absent peripheral pulses

When assessing a 22yo patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The O2 is 90% with O2 delivery at 6L/min nasal cannula. Which action is most appropriate? a. increase flow rate of oxygen to 10L/min and reassess the patient after 10min b. assist patient in using incentive spirometer and splint his chest with pillow as he coughs c. administer ordered morphine sulfate to patient to decrease his anxiety and reduce the hyperventilation d. switch patient to nonrebreather at 95% to 100% fraction of inspired oxygen and call the PCP to discuss status

the nurse is teaching the mother of a child with cystic fibrosis how to do postural drainage. the nurse should tell the mother to a. use heel of her hand during percussion b. change child's position Q20 min c. do percussion after child eats and at bedtime d. use cupped hands during percussion

the nurse on a pediatric unit has received her assignment for the day. which of the following patients is the priority to see first? a. 11yo with pneumonia being discharged today b. 6yo with bronchitis and antibiotic infusing via IV @ 30mL/hr c. 3yo with asthma who is saturation at 94% on room air d. 17yo with pleural effusion complaining of 7/10 pain

what parts of the body can be affected by autoimmune diseases? a. immune b. cardiac/pulmonary c. musculoskeletal d. all

you are providing care to a patient with a chest tube. on assessment of the drainage system, you note continuous bubbling in water seal chamber and oscillation. which of the following is correct nursing intervention for this type of finding? a. reposition patient because tubing is kinked b. continue to monitor drainage system c. increase suction to drainage system until bubbling stops d. check drainage system for an air leak

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? a. "I should notify my doctor if my feet or legs start to swell." b. "My doctor told me to call his office if my pulse rate decreases below 60." c. "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." d. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

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