Quizzes
You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently?
Airway patency
The client diagnosed with asthma has been prescribed a glucocorticoid inhaled medication. Which information should the nurse teach regarding this medication? A- Do not abruptly stop taking this medication; it must be tapered off B- immediately rinse the mouth following administration of the drug C- Hold the medication in the mouth for 15 seconds before swallowing D- Take the medication immediately when an attack starts
B
The recovery room nurse is admitting a patient from the OR following the patient's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient? A- Heart rate and rhythm B- Airway patency C- Core body temperature D- Skin integrity
B
A nurse is assessing a client who comes to the clinic for care. Which findings suggest bacterial pneumonia? A- Nonproductive cough and normal temp B- sore throat and abdominal pain C- hemoptysis and dysuria D- Dyspnea and wheezing
D
A 64 year old patient and his wife have presented to their primary care provider. The patient's wife has prompted her husband to seek care because she is worried about his apneic episodes and loud snoring. The husband had earlier undergone a diagnostic workup for obstructive sleep apnea (OSA) and been diagnosed with the disease but is not motivated to treat his health problem. How can the nurse at the clinic best characterize the risk of OSA? A- "Sleep apnea actually increases your risk of having a stroke or heart attack" B- "people with sleep apnea are much more susceptible to infections in their sinuses and throat" C- "sleep apnea has actually been identified as a risk factor for throat cancer" D- "without treatment, your apnea could progress to chronic obstructive lung disease"
A
A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client A- has wheezes in the right lung lobes B- has a respiratory rate of 28 breaths/min C- reports of SOB D- cannot perform activities of daily living
A
A nurse is admitting a new pt. who has been admitted w/ a diagnosis of COPD exacerbation. How can the nurse best help the pt. achieve the goal of maintaining effective oxygenation? A- Teach the pt. strategies for promoting diaphragmatic breathing B- Administer supplementary oxygen by non-rebreather mask C- Teach the pt. to perform airway suctioning D- Assist the pt. in developing an appropriate exercise program
A
A nurse is evaluating the diagnostic study data of a patient with suspected cystic fibrosis (CF). Which of the following test results is associated with a diagnosis of cystic fibrosis? A- elevated sweat chloride concentration B- presence of protein in the urine C- positive phenylketonuria D- malignancy on lung biopsy
A
A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery? A- Leg exercises improve circulation and prevent venous thrombosis. B- Leg exercises help to prevent pressure sores to the sacrum and heels. C- Leg exercises increase the patient's muscle mass postoperatively. D- Leg exercise help increase the patient's level of consciousness after surgery.
A
A patient who has been hospitalized for 2 days has been receiving normal saline IV at 100 ml/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding by the nurse is the priority to report to the health care provider? A- Gradually decreasing level of consciousness (LOC) B- Oral temperature of 100.1° F with bibasilar lung crackles C- Serum sodium level of 138 mEq/L (138 mmol/L) D- Weight gain of 2 pounds (1 kg) above the admission weight
A
A patient with advanced lung cancer is admitted to the emergency department with urinary retention caused by renal calculi. Which of these laboratory values will require the most immediate action by the nurse? A- Serum calcium is 18 mEq/L. B- Serum potassium is 5.1 mEq/L. C- Arterial oxygen saturation is 91%. D- Arterial blood pH is 7.32.
A
A patient with emphysema is experiencing SOB. To relieve this patient's symptoms, the nurse should assist her into what position? A- sitting upright, leaning forward slightly B- Low Fowler's, with the neck slightly hyperextended C- Prone D- Trendelenburg
A
The anesthetist is coming to the surgical admissions unit to see a patient prior to surgery scheduled for tomorrow morning. Which of the following is the priority information that the nurse should provide to the anesthetist during the visit? A- Latex allergy B- Last bowel movement C- Difficulty falling asleep D- Number of pregnancies
A
The nurse has administered 3% saline to a patient with hyponatremia. Which one of these assessment data will require the most rapid response by the nurse? A- There are crackles audible throughout both lung fields. B- The patient's radial pulse is 105 beats/minute. C- There is sediment and blood in the patient's urine. D- The blood pressure increases from 120/80 to 142/94.
A
The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? A- Crackles in the lung bases B- low pitched rhonchi during expiration C- pleural friction rub D- sibilant wheezes
A
When assessing a patient with increased extracellular fluid (ECF) osmolality, the priority assessment for the nurse to obtain is A- mental status. B- skin turgor. C- capillary refill. D- heart sounds.
A
When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake A- if the oral mucosa feels dry B- as soon as changes in level of consciousness (LOC) occur C- in the late evening hours D- when the patient feels thirsty
A
A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients? A- Passive range of motion exercise for the upper and lower extremities B- Early ambulation and the use of compression stockings C- Incentive spirometry and deep breathing and coughing exercises D- Maintenance of SpO2 levels greater than 90% using supplementary oxygen
B
A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates? A- pneumothorax B- Fail chest C-ARDS D- Tension pneumothorax
B
An asthma nurse educator is working with a group of adolescent asthma patients. What intervention is most likely to prevent asthma exacerbations among these patients? A- Encouraging patients to carry a corticosteroid rescue inhaler at all times B- Educating patients about recognizing and avoiding asthma triggers C- Teaching patients to utilize alternative therapies in asthma management D- Ensuring that patients keep their immunizations up to date
B
Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." The nurse will immediately check for A- an elevated serum potassium level. B- the presence of Chvostek's sign. C- bleeding on the patient's dressing. D- a decreased thyroid hormone level.
B
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.1 mEq/L. Of the following medications that the patient has been taking at home, the nurse will be most concerned about A- lantus insulin 24 U subcutaneously every evening B- ibuprofen (Motrin) 400 mg every 6 hours. C-oral digoxin (Lanoxin) 0.25 mg daily. D-metoprolol (Lopressor) 12.5 mg orally daily.
C
A recently admitted patient has a small cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for A- Increased total urinary output B- rapid and unexpected weight loss C- decreased serum sodium level D- elevation of serum hematocrit
C
An ER nurse is caring for a client who is having an asthma attack. What is the preferred intervention to alleviate this client's airflow obstruction? A- administer corticosteroids by metered dose inhaler B- administer inhaled anticholinergics C- administer an inhaled beta-adrenergic agonist D- utilize a peak flow monitoring device
C
As status asthmaticus worsens, the nurse would expect which acid-base imbalance? A- Respiratory alkalosis B- Metabolic alkalosis C- Respiratory acidosis D- Metabolic acidosis
C
The nurse is assessing a pt. whose respiratory disease is characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this pt.? A- signs of oxygen toxicity B- chronic chest pain C- a barrel chest D- long, thin fingers
C
When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated with multiple draining wounds, the most accurate assessment to include is A- presence of edema B- skin turgor C- daily weight D- hourly urine output
C
A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? A- "Getting the flue can complicate pneumonia" B- "influenza vaccine will prevent typical pneumonias" C- "influenza is the major cause of death in the U.S." D- "Viruses like influenza are the most common cause of pneumonia"
D
A client reports nasal congestion, sneezing, sore throat, and coughing up yellow mucus. The nurse assesses the client's temp. as 100.2 degrees F. The clients states this is the third episode this season. The highest priority nursing diagnosis is A- Acute pain related to upper airway irritation B- Deficient fluid volume related to increased fluid needs C- Deficient knowledge related to prevention of upper respiratory infections D- Ineffective airway clearance related to excess mucus production
D
A clinic nurse is caring for a pt. who has just been diagnosed with COPD. the pt. asks the nurse what he could have done to minimize the risk of contracting this disease. What would be the nurse's best answer? A- "The most important risk factor for COPD is exposure to occupational toxins." B- "The most important risk factor for COPD is inadequate exercise." C- "The most important risk factor for COPD is exposure to dust and pollen." D- "The most important risk factor for COPD is cigarette smoking."
D
A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor is A- urinary output B- peripheral pulses C- peripheral edema D- lung sounds
D
A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as A- metabolic alkalosis B- metabolic acidosis C- respiratory acidosis D- respiratory alkalosis
D
After diagnosing a client with latent pulmonary tuberculosis, the physician tells family members that the client must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? A- 3 to 5 days B- 1 to 3 weeks C- 2 to 4 months D- 6 to 12 months
D
Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? A- administer the KCl as a rapid IV bolus B- Give the KCl only through a central venous line C- add no more than 40 mEq/L to a liter of IV fluid D- infuse the KCl at a rate of 10-20 mEq/hour
D
The nurse is planning patient teaching for a patient who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? A- Upon the patient's admission to the postanesthesia care unit (PACU) B- During the intraoperative period C- When the patient returns from the PACU D- As soon as possible before the surgical procedure
D
The nurse knows that the following is a chest tube rule. Choose all that apply. A- keep tubing straight B- keep below level of client's chest C- strip tubing every hour D- mark drainage amounts each shift
A, B, D