Respiratory System
A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy?
"It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion."
A client is diagnosed with thrombophlebitis. The client states, "I am worried about getting a clot in my lungs that will kill me." The nurse's initial response should be to:
Discuss the client's concerns
A client is on mechanical ventilation. When condensation collects in the ventilator tubing, the nurse should:
Drain the fluid from the tubing
A client asks the nurse several questions about fluid and electrolyte imbalances. Before responding, the nurse recalls that where a semipermeable membrane divides two solutions in the human body the solution with the greater number of particles:
Draws water in its direction
A client has chronic obstructive pulmonary disease (COPD) and cor pulmonale. When teaching about nutrition, the nurse instructs the client to:
Eat small meals six times a day to limit oxygen needs
The nurse assesses a male client with a preliminary diagnosis of cancer of the urinary bladder. The nurse recalls that which sign or symptom is a common early sign of cancer of the urinary system?
Hematuria
A client appears anxious, exhibiting 40 shallow respirations per minute. The client complains of feeling dizzy and lightheaded and of having tingling sensations of the fingertips and around the lips. The nurse concludes that the client's complaints probably are related to:
Hyperventilation
A client who is suspected of having Cushing syndrome is admitted to the hospital. The nurse plans to monitor this client for:
Hypokalemia
For what common early clinical manifestation should the nurse monitor in clients with renal carcinoma?
Intermittent hematuria
During a client's immediate postoperative period after a laryngectomy, a nursing priority is to:
Keep the trachea free of secretions
The nurse is providing care during the immediate postoperative period for a client that had a radical neck dissection. The best method to assess for stridor is:
Listen with a stethoscope over the trachea
A client with an ileal conduit is being prepared for discharge. As part of the discharge teaching, the nurse instructs the client to:
Maintain fluid intake of at least 2 L daily
What must the nurse do when performing tracheostomy care?
Maintain sterile technique during the procedure
A client with chronic kidney disease is on a restricted protein diet. The nurse provides teaching about high biologic-value (HBV) protein foods. An understanding of the rationale for this diet is demonstrated when the client states that HBV protein foods are:
Necessary to prevent muscle wasting
chest tube is inserted into a client who was stabbed in the chest and is attached to a closed-drainage system. Which is an important nursing intervention when caring for this client?
Observe for fluid fluctuations in the water-seal chamber.
A client is experiencing dyspnea. In which position should the nurse place the client?
Orthopneic
The nurse is providing postoperative care to a client who is receiving a progressive diet as tolerated following the client's head and neck surgery. What action should the nurse take?
Place suction apparatus at the bedside
The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take?
Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula
A health care provider prescribes metaproterenol (Allupent) for a client who was recently admitted to the hospital. For what therapeutic effect should the nurse monitor the client?
Relaxed bronchial spasm
To evaluate the effectiveness of a chest tube inserted in a client with a pneumothorax, the nurse assesses for:
Return of breath sounds
A nurse checking the perineum of a client with a radium implant for cervical cancer observes the packing protruding from the vagina. The nurse notifies the health care provider to have the packing removed. What is the primary reason that the packing needs to be removed immediately?
The radioactive packing will injure healthy tissue.
A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus?
Unilateral chest pain
The laboratory values of a client with renal calculi reveal a serum calcium within expected limits and an elevated serum purine. The nurse concludes that the stone probably is composed of:
Uric acid
A client's retention catheter and continuous bladder irrigation (CBI) are to be removed two days after prostate surgery, and the nurse discusses what to expect with the client. Which expectation verbalized by the client indicates that the teaching is understood?
"Some burning on urination is expected."
During admission a client appears anxious and says to the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best response?
"You are concerned about your diagnosis."
What must the nurse determine before discontinuing airborne precautions for a client with pulmonary tuberculosis?
Sputum is free of acid-fast bacteria.
To make a definitive client diagnosis of tuberculosis, the nurse expects what diagnostic test to be prescribed?
Sputum tested for acid fast bacilli
A client who is receiving peritoneal dialysis reports severe respiratory difficulty. What immediate action should the nurse implement?
Auscultate the lungs.
A client is diagnosed with emphysema. For what long-term problem should the nurse monitor this client?
Carbon dioxide retention
A nurse is teaching a client with tuberculosis about recovery after discharge from the hospital. Which instruction is the priority?
Consistently taking prescribed medication
During the evening after a paracentesis, the nurse identifies that the client, although denying any discomfort, is very anxious. The best nursing approach is to:
Explore the client's concerns while administering the prescribed anxiolytic
A nurse reviews the history of a client who is hospitalized with a diagnosis of urinary calculi and identifies that which factor may have contributed to the development of the calculi?
History of hyperparathyroidism
The nurse provides instructions to a client who will be using an incentive spirometer postoperatively. During the client's return demonstration, the nurse concludes that the teaching has been effective when the client:
Inhales deeply through the mouthpiece, holds the breath for two seconds, and then exhales
What is the underlying rationale why a nurse assesses a client with emphysema for clinical indicators of hypoxia?
Loss of aerating surface
The nurse is caring for a client that has a lesion in the right upper lobe. A diagnosis of tuberculosis (TB) has been made. What are the clinical manifestations of tuberculosis?
Night sweats and blood-tinged sputum
A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed-drainage system. Which is an important nursing intervention when caring for this client?
Observe for fluid fluctuations in the water-seal chamber
During an exacerbation of multiple sclerosis a client complains of urinary urgency and frequency. What is the most appropriate initial nursing action?
Palpate the suprapubic area of the abdomen.
A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client?
Palpate the surrounding area for crepitus
A client is diagnosed with pulmonary tuberculosis, and the health care provider prescribes a combination medication, Rifamate, composed of rifampin (Rifadin) and isoniazid (INH). The nurse evaluates that the teaching regarding the drug is effective when the client says, "The most important thing I must do is:
Continue taking the medicine even after I feel better."
A client with chronic obstructive pulmonary disease (COPD) reports a five-pound weight gain in one week. The nurse recalls that the complication that may have precipitated this weight gain is:
Cor pulmonale
A client is admitted to the hospital for medical treatment of bronchopneumonia. What test result should the nurse examine to help determine the effectiveness of the client's therapy?
Culture and sensitivity tests of sputum
Thick mucous gland secretions, elevated sweat electrolytes, meconium illeus, and difficulty maintaining and gaining weight are associated with this autosomal recessive disorder:
Cystic fibrosis
A nurse instructs a client with a history of frequent urinary tract infections to drink cranberry juice to:
Decrease the urinary pH
What breathing exercises should the nurse teach a client with the diagnosis of emphysema?
Diaphragmatic exercises to improve contraction of the diaphragm.
Radium inserted in the vagina of a client now is being removed. What safety precaution should the nurse employ when assisting with the radium removal?\
Ensure that long forceps are available for removing the radium.
A client is receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for which response to the medication?
Excessive loss of potassium ions
A client is admitted for a rhinoplasty. To monitor for hemorrhage after the surgery, the nurse should assess specifically for the presence of:
Excessive swallowing
A nurse assesses a newly admitted client with renal colic to determine the signs and symptoms that are present. The nurse assesses the client for which primary subjective symptom?
Flank discomfort
Nursing intervention for a client who is hyperventilating should focus on providing reassurance and:
Having the client breathe into a paper bag
A client is admitted to the hospital with a diagnosis of cancer of the liver with ascites and is scheduled for a paracentesis. What nursing intervention is appropriate to include in the client's plan of care?
Having the client void before the procedure
A health care provider diagnoses late-stage (tertiary) syphilis in a client. Which statement made by the client supports this diagnosis?
I'm having trouble keeping my balance."
A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, the nurse plans to:
Increase fluid intake to at least 2 L a day
A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client's PaO2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first?
Increase the oxygen flow rate per facility protocol.
A nurse gave a client naloxone (Narcan). To evaluate the effectiveness of the medication, the nurse should assess for:
Increased respiration
A nurse is administering gold salts to a client with the diagnosis of rheumatoid arthritis. For which adverse effect of this drug should the client be monitored?
Kidney damage
A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do?
Mark the time and fluid level on the side of the drainage chamber.
A nurse is caring for a client with a ureteral calculus. Which are the most important nursing actions? Select all that apply.
Monitoring intake and output Straining the urine at each voiding Administering the prescribed analgesic
A client that is postoperative hip replacement is receiving morphine by patient-controlled analgesia and has a respiratory rate of 6 breaths/min. What intervention should the nurse anticipate?
Naloxone administration
A 40-year-old client scheduled for a hemicolectomy because of ulcerative colitis asks if having a hemicolectomy means wearing a pouch and having bowel movements in an abnormal way. Which is the best response by the nurse?
No, only part of the colon is removed and the rest reattached."
A nurse is notified that a victim of a gunshot wound to the right side of the chest is being transported to the emergency department. To prepare for the client, the priority nursing intervention is to:
Obtain equipment for chest tube insertion
A nurse is providing education to a co-worker who is caring for a client who is scheduled to have a thoracentesis for a pleural effusion. Which statement would be appropriate for the nurse to include?
Rapid removal of large amounts of pleural fluid may precipitate cardiovascular collapse.
A postoperative client is being weaned from mechanical ventilation. What is the most important factor for the nurse to consider when organizing activities?
Remain with the client to assess responses.
A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" The nurse explains that the purpose of the chest tube is to:
Remove air from the pleural space
What data about the fluid in the water-seal chamber of a closed chest drainage system provide support for the nurse's conclusion that the system is functioning correctly?
Rises with inspiration and falls with expiration.
A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" What likely cause of the spontaneous pneumothorax should the nurse's response take into consideration?
Rupture of a subpleural bleb
A nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. What is the most important intervention for the nurse to include in this plan?
Taking medications as prescribed
A client who is receiving chemotherapy for lung cancer has nausea and vomiting because of the therapy. The client wants to know if it is true that smoking marijuana will help. What is the nurse's best response?
Tetrahydrocannabinol is an ingredient in marijuana that acts as an antiemetic in some people."
A human immunodeficiency virus (HIV)-negative client with a history of chronic obstructive pulmonary disease (COPD) requests the nurse to read the results of the client's Mantoux test for tuberculosis. The test site has a 10-mm area of induration with 5 mm of erythema. How should the nurse interpret the finding?
The client has been exposed to the pathogen that causes tuberculosis
After a gastroscopy, the nurse assesses the client for the return of the gag reflex by:
Touching the pharynx with a tongue depressor
What emergency equipment should the nurse ensure is readily available at the bedside after a client has surgery for a malignant lesion on a vocal cord?
Tracheostomy set and oxygen
To help prevent a cycle of recurring urinary tract infections, the nurse should plan to instruct a female client to:
Urinate as soon as possible after intercourse
What psychological problem do clients receiving hemodialysis often experience?
reactive depression
A client is scheduled for a pulmonary function test. The nurse explains that during the test one of the instructions the respiratory therapist will give the client is to breathe normally. What should the nurse teach is being measured when the client follows these directions?
tidal volume
To facilitate micturition in a male client, the nurse should instruct him to:
v
What should the nurse do to obtain an accurate urine output for a client with a continuous bladder irrigation (CBI)?
Subtract the volume of irrigant from the total drainage.
A client who is a pipe smoker is diagnosed with cancer of the tongue. A hemiglossectomy and right radical neck dissection are performed. To ensure airway patency while the client is in the postanesthesia care unit, the nurse should:
Suction as needed
A nurse is caring for a client who had a kidney transplant. Which test is most important for determining whether a client's newly transplanted kidney is working effectively?
serum creatinine
What information should the nurse give the client after removal of a foley catheter?
"Void in the plastic measuring hat placed in the toilet and then contact the nurse."
Nitrofurantoin (Macrobid) 0.1 gm is prescribed for a client with a urinary tract infection. Each tablet contains 50 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablets
2
A man who has 40% of the body surface area burned is admitted to the hospital. Fluid replacement of 7200 mL during the first 24 hours has been prescribed. The nurse calculates that the hourly intravenous (IV) fluid should be: ___ mL/hr (Record your answer using a whole number)
303
During an eight-hour shift a client has a 6-ounce cup of tea and 360 mL of water; the client vomits 100 mL, and the intravenous (IV) fluids instilled equaled the urinary output. What is this client's fluid balance at the end of this eight-hour period that the nurse must document on the client's intake and output record?
440ml
A nurse is caring for a variety of clients. For which client is it most essential for the nurse to implement measures to prevent pulmonary embolism?
59-year-old who had a knee replacement
A client has a leak of thoracic duct following a radical neck surgery. The nurse expects that the postoperative plan of care will include:
A chest tube, total parenteral nutrition (TPN), and bed rest
A client complains of left-sided chest pain after the client finished playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify:
Absence of breath sounds on auscultation
A nurse identifies 12 mm of induration at the site of a Mantoux test when a client returns to the health office to have it read. What explanation of this result should the nurse give to the client?
Additional tests are needed, such as a chest x-ray.
A client is admitted to the hospital with severe flank pain, nausea, and hematuria caused by a ureteral calculus. A lithotripsy is scheduled. What is the priority nursing action when caring for this client?
Administer the prescribed analgesic.
A client with a tentative diagnosis of lung cancer is scheduled for a mediastinoscopy with biopsy. What is a priority nursing action?
Advise the client to avoid eating or drinking anything for several hours before the test.
A client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client?
Air will move from the lung into the pleural space.
A client has cancer of the prostate, and a suprapubic prostatectomy is to be performed. The client asks the nurse how this surgery differs from other prostatic procedures. What difference associated with a suprapubic prostatectomy should the nurse include in the response?
An incision is made directly into the urinary bladder.
What nursing action will limit hypoxia when suctioning a client's airway?
Apply suction only after catheter is inserted.
The nurse is preparing to discharge a client who presented to the emergency room for an acute asthma attack. The nurse notes that upon discharge the health care provider has prescribed theophylline (Theo-Dur) 300 mg orally to be taken daily at 9:00 AM. The nurse should teach the client to take the medication:
At a specific time prescribed.
The nurse provides discharge instructions to a client who had a rhinoplasty. The client will have packing in place for several days after discharge from the hospital. The instructions should include:
Avoid items that may trigger sneezing
Nursing care specific to a child with Wilm's Tumor, also known as nephroblastoma, includes:
Avoid unnecessary handling of abdomen
A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client's anxiety level?
Cannula
A client with a urinary retention catheter reports discomfort in the bladder and urethra. What should the nurse do first?
Check the patency of the catheter.
After thoracic surgery a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, the nurse should:
Check the system for air leaks
A nurse is caring for a client who had a kidney transplant. What sign indicates that the client may be rejecting the transplanted kidney?
Fever
A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the health care provider?
Urine output of 20 to 30 mL/hr
A client newly diagnosed with tuberculosis has a productive cough. The most appropriate nursing intervention is to teach the client to:
Use disposable tissues
A nurse is caring for a client with an indwelling urinary catheter. What is the most important action for the nurse to implement when irrigating the bladder?
Use sterile equipment.
Soft swishing sounds of breathing are heard when the nurse auscultates a client's chest. What term should be used when documenting this assessment?
Vesicular breath sounds
When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. The nurse should document:
Vesicular breath sounds
When performing a peritoneal dialysis procedure, the nurse should:
Warm dialysate solution slightly before instillation
A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. What precautions should the nurse take?
Wear a particulate respirator when caring for the client.
A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when teaching the client about health practices that may help decrease future urinary tract infections?
Wear cotton underpants
A client is to have hemodialysis. What must the nurse do before this treatment?
Weigh the client to establish a baseline for later comparison.
While a client with a fractured femur is being prepared for surgery, the client exhibits cyanosis, tachycardia, dyspnea, and restlessness. The nurse's first action should be to:
Administer oxygen by mask
A client with lymphosarcoma is receiving allopurinol (Zyloprim) and methotrexate (Rheumatrex). The nurse can help the client prevent complications related to uric acid nephropathy by administering the:
Allopurinol and encouraging the intake of fluid
A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, the nurse expects to identify:
Altered mental status
A client reports to a health clinic because a sexual partner recently was diagnosed as having gonorrhea. The health history reveals that the client has engaged in receptive anal intercourse. The nurse should assess the client for:
Anal itching
A client who had a kidney transplant develops leukopenia three weeks after surgery. The nurse concludes that the leukopenia probably is caused by:
Antirejection medications
On the second postoperative day after a pyelolithotomy, a nurse observes a large amount of bright red blood seeping through the dressing. What is the priority nursing intervention?
Apply direct pressure against the dressing
During the postoperative period after surgery for a kidney transplant, the client's creatinine level is 3.1 mg/dL. What should the nurse do first in response to this laboratory result?
Assess for decreased urine output.
The nurse is providing postoperative care to a client on the second day after the client had a coronary artery bypass surgery. When assessing the water-seal chamber of the chest drainage device, the nurse observes that the fluid no longer fluctuates. The nurse should:
Assess for obstructions in the chest tube
A client with chronic obstructive pulmonary disease is admitted to the hospital with a tentative diagnosis of pleuritis. When caring for this client the nurse should:
Assess for signs of pneumonia
The nurse is preparing to administer an antibiotic that has been newly prescribed. The nurse plans to administer the antibiotic via a secondary line into the primary infusion of 0.9% sodium chloride. Shortly after initiation of the antibiotic piggyback, the client becomes restless and flushed, and the client begins to wheeze. The nurse determines that appropriate first actions will be to stop the antibiotic infusion and:
Assess the client's respiratory status.
Endotracheal intubation and positive-pressure ventilation are instituted because of a client's deteriorating respiratory status. What is the priority nursing intervention?
Assess the client's response to the mechanical ventilation
The nurse is monitoring a client who is receiving peritoneal dialysis. After the dialysate has infused, the client reports severe respiratory difficulty. What immediate action should the nurse implement?
Auscultate breath sounds.
A client with emphysema experiences shortness of breath and uses pursed-lip breathing and accessory muscles of respiration. The nurse determines that the cause of the dyspnea is:
Difficulty in expelling the air trapped in the alveoli
A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis?
Diminished breath sounds on auscultation
A client with a history of chronic kidney disease is hospitalized. The nurse assesses the client for signs of related kidney insufficiency, which include:
Edema and pruritus
After a thoracentesis is performed for pleural effusion, a client returns to the health care provider's office for a follow-up visit. Which client statement leads the nurse to suspect a recurrence of the pleural effusion?
I get a sharp pain when I take a deep breath."
A client with a history of hemoptysis and cough for the last six months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. The nurse's priority is to:
Immediately contact the primary healthcare provider
A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs?
Increased restlessness
A client with a history of benign prostatic hypertrophy asks whether cranberry juice prevents bladder infections. The nurse replies that cranberry juice may be helpful because it:
Increases acidity of the urine
A nurse is caring for a client who is scheduled to have a paracentesis. Immediately before the procedure, the nurse asks the client to void because a full bladder:
Increases the danger of puncture during the procedure
A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin resistant entercoccus (VRE). After notifying the health care provider, which action should the nurse take to decrease the risk of transmission to others?
Move the client to a private room
The nurse concludes that a client who had a transurethral vaporization of the prostate understands the discharge teaching when the client says, "I should:
Notify my primary health care provider if my urinary stream decreases."
A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. This should be documented in the medical record as:
Overflow incontinence
The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. What is the priority nursing intervention?
Place client in a high-Fowler position
An older adult client is admitted to the hospital with a diagnosis of chronic kidney disease. The nurse reviews the client's medical record. Which clinical finding is a priority to be communicated to the primary health care provider? POTCION 6
Potassium level
A nurse is reviewing the laboratory reports of a client with a diagnosis of end-stage renal disease. What test result should the nurse anticipate?
Potassium of 6.3 mEq/L
Which action should the nurse implement when performing tracheal suctioning for a client with a tracheostomy?
Preoxygenate the client before suctioning
A nurse observes a client with acute bronchitis and emphysema sitting up in bed, appearing anxious and dyspneic. What should the nurse do first?
Provide oxygen at 2 L per minute
A client is admitted to the emergency department with a stab wound of the chest. What is the priority when the nurse performs a focused assessment of the client's response to this injury?
Quality and depth of respirations
A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. The priority nursing assessments are:
Quality of respirations and presence of pulses
A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?
Restlessness
A client was treated with a radium implant for cancer of the cervix. What information is important for the nurse to teach the client when giving discharge instructions?
Return for follow-up care.
A nurse must administer streptomycin 1 g intramuscularly (IM) to a client with tuberculosis. The vial contains 500 mg/mL. How much solution must the nurse administer? Record your answer using a whole number. ___ mL
2
A client is scheduled to receive general anesthesia during an upcoming surgery. The nurse provides education about common side effects of general anesthesia. The nurse concludes that the teaching has been effective when the client states, "Immediately after surgery I may experience:
A sore throat."
Pyridoxine (vitamin B6) and isoniazid (INH) are prescribed as part of the chemotherapy protocol for a client with tuberculosis. Which response indicates to the nurse that vitamin B6 is effective?
Absence of numbness and tingling in extremities
A client who has repeated episodes of cystitis is scheduled for a cystoscopy to determine the possibility of urinary tract abnormalities. The client asks the nurse to describe the procedure. The nurse's most appropriate response is, "This procedure is:
The visualization of the inside of the bladder with an instrument connected to a source of light."
A graduate nurse reminds a client who just had a laryngoscopy not to take anything by mouth until instructed to do so. What conclusion should be made about this intervention by the nurse preceptor who is evaluating the performance of the graduate nurse?
Appropriate, because early eating or drinking after such a procedure may cause aspiration
A nurse evaluates that a client with chronic kidney disease understands an adequate source of high biologic-value (HBV) protein when the food the client selects from the menu is:
Cottage cheese
A client with the diagnosis of inhalation anthrax is admitted to the intensive care unit. It is most important for the nurse to make a focused assessment of which body system?
Respiratory
A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's blood studies indicate pH 7.30, Po2 60 mm Hg, Pco2 55 mm Hg, and HCO3 23 mEq/L. The nurse concludes that the client is experiencing:
Respiratory acidosis
A client with cancer of the prostate requests the urinal at frequent intervals but either does not void or voids in very small amounts. What does the nurse conclude is most likely the causative factor?
Retention
A client has a chest tube inserted to treat a right hemopneumothorax. In which position should the nurse place the client to facilitate chest drainage?
Right side-lying
What should the nurse include in the plan of care for a client who just had a total laryngectomy?
Suctioning the tracheostomy tube whenever necessary
A nurse is assessing the urine of a client with a urinary tract infection. For which characteristic should the nurse assess each specimen of urine?
clarity
A nurse is assessing the urine of a client with a urinary tract infection. What appearance should the nurse expect this client's urine to have?
cloudy
In the early postoperative period after a transurethral resection of the prostate, the most common complication the nurse should monitor for is:
hemorrhage
A pathology report states that a client's urinary calculus is composed of uric acid. Which should the nurse instruct the client to avoid?
liver
A client responds well after extensive pulmonary surgery for lung cancer and is discharged. A week after discharge the home care nurse observes the client's downcast eyes and lack of interest in the environment. The client's family states that this behavior started a few days after discharge. The nurse understands that the client's response is:
Expected, but needs to be addressed
A client sustains a stab wound to the chest, and a chest tube is inserted. Later the client's chest tube appears to be obstructed. What is the most appropriate nursing action?
Instruct the client to cough.
The nurse obtains a laboratory report that shows acid-fast rods in a client's sputum. Which disorder should the nurse consider may be related to these results?
Mycobacterium tuberculosis
The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis results. The nurse concludes that the presence of what substance in the urine needs to be reported to the health care provider?
large proteins
A client with a history of pulmonary emboli is taking warfarin (Coumadin) daily. The nurse teaches the client about foods that are appropriate to consume when taking this medication. The nurse evaluates that the client needs further teaching when the client states:
"Dark green leafy vegetables are high in vitamin K and should be eaten to prevent clotting.
A client who has ovarian cancer is to receive intravenous chemotherapy. Before the infusion, the nurse teaches the client how to use imagery to maximize the effects of the chemotherapy. What statement specifically relates to this alternative therapy?
"Focus on the droplets of chemotherapy attacking the cancer cells."
A client with tuberculosis is started on a chemotherapy protocol that includes rifampin (RIF). The nurse evaluates that the teaching about rifampin is effective when the client states:
"I can expect my urine to turn orange from this medication."
The nurse provides teaching about self-care management to a client who recently was diagnosed with emphysema. The nurse concludes that further teaching is needed when the client states:
"I will maintain complete bed rest.
While the nurse is at the bedside of a client in acute renal failure, the client states, "My health care provider said that I will be getting some insulin. Do I also have diabetes?" What is the best nursing response?
"No, the insulin will help your body handle the increased potassium level."
A client is waiting for a kidney transplant. What explanation should the nurse include when teaching the client about the transplant?
"You will require immunosuppressive drugs daily for the rest of your life."
A client with urge incontinence is receiving oxybutynin (Ditropan XL) 30 mg orally. Each tablet contains 5 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablets
6
A client has undergone surgery with general anesthesia. Within how many hours after surgery should the nurse notify the health care provider if the client does not void?
8 hours
A client with chronic kidney disease has been on hemodialysis for two years. The client relates to a nurse in the dialysis unit in an angry, critical manner and frequently does not follow the prescribed diet or take prescribed medications. What does the nurse identify as the most likely underlying cause of this behavior?
A defense against underlying depression and fear
A client with chronic renal failure has been on hemodialysis for two years. The client communicates with the nurse in the dialysis unit in an angry, critical manner and is frequently noncompliant with medications and diet. The nurse can best intervene by first considering that the client's behavior is most likely:
A defense against underlying depression and fear
A nurse is caring for a client after a left pneumonectomy for cancer. The nurse palpates the client's trachea routinely. What is the rationale for this nursing intervention?
A mediastinal shift may have occurred.
The nurse is caring for a client after a right pneumonectomy for cancer. As part of the assessment, the nurse palpates the client's trachea. What is the rationale for this assessment?
A mediastinal shift may have occurred.
A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client?
Absence of breath sounds over the affected area
A client has a permanent colostomy. During the first 24 hours there is no drainage from the colostomy. The nurse concludes that this is a result of the:
Absence of intestinal peristalsis.
A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), the nurse should:
Administer oxygen at a low concentration to maintain respiratory drive
A client is brought to the emergency department after a bee sting. The client has a history of allergies to bees and is having difficulty breathing. What client reaction should cause a nurse the most concern?
Asphyxia
A client returns from a bronchoscopy, and the nurse provides the client with instructions to not consume any food or drink any fluids for several hours. The nurse explains that these measures are taken to prevent:
Aspiration
The nurse evaluates that the preoperative teaching regarding a bronchoscopy was understood when the client states, "I recognize I cannot eat or drink for several hours after the procedure to prevent:
Aspiration of food."
A client who experienced smoke inhalation has a negative chest x-ray and arterial blood gases that demonstrate PaO2 of 70 mm Hg, PaCO2 of 45 mm Hg, and pH of 7.35. What intervention should the nurse anticipate will be prescribed by the health care provider?
Breathing exercises
A nurse is caring for a client who is admitted to the hospital with severe dyspnea and a diagnosis of cancer of the lung. The nurse concludes that the severe dyspnea probably is caused by:
Bronchial obstruction or pleural effusion
The health care provider prescribes aminophylline to be given intravenously for the client experiencing an acute asthma attack. The nurse should instruct the client that the purpose of this medication is to act as a(n):
Bronchodilator.
A nurse is caring for a client with acute renal failure. Which findings should the nurse anticipate when reviewing the laboratory report of the client's blood level of calcium, potassium, and creatinine? Select all that apply.
Calcium: 7.6 mg/dL Potassium 6.0 mEq/L Creatinine: 3.2 mg/dL
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD?
Cardiac problems
A client who is to be admitted for minor surgery has a chest radiograph as part of the presurgical physical. The nurse is notified that the radiograph reveals that the client has pulmonary tuberculosis. What evidence of tuberculosis is provided by the radiograph?
Cavities caused by caseation
After a transurethral resection of the prostate, a client has a three-way indwelling catheter inserted with a continuous bladder irrigation. The client complains of a need to void. What should the nurse do first?
Check the tubing connected to the client's collection bag to see if it is draining
A client admitted to the hospital in the oliguric phase of acute renal failure estimates that the urine output for the last 12 hours was less than 240 mL. The nurse reviews the plan of care and notes a prescription for 900 mL of water to be given orally over the next 24 hours. The nurse concludes that this amount of fluid was prescribed to:
Compensate for both insensible and expected output over the next 24 hours
The nurse provides discharge teaching to a client with tuberculosis and reinforces that the treatment measure with the highest priority is:
Consistently taking prescribed medication
The nurse is developing a plan of care for a client that had a chest tube removed. To promote respiratory exchange, the plan should include:
Coughing and deep breathing every hour
A client is admitted to the intensive care unit with pulmonary edema. What clinical finding does the nurse expect when performing the admission assessment?
Crackles at bases of the lungs
A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side?
Decreased sounds
A client develops kidney damage as a result of a transfusion reaction. What is the most significant clinical response that the nurse should assess when determining kidney damage?
Decreased urinary output
Which clinical manifestation should a nurse expect a client with diabetes insipidus to exhibit?
Decreased urine osmolarity
A nurse administers beclomethasone (QVAR) by inhalation to a client with asthma, and the client asks why this medication is necessary. What should the nurse explain is the purpose of this pharmacologic therapy?
Decreases inflammation
After a successful kidney transplant for a client with end-stage kidney disease, the nurse anticipates that laboratory studies will demonstrate:
Decreasing serum creatinine
A client is admitted to the hospital with a tentative diagnosis of urinary retention related to benign prostatic hyperplasia. The health care provider notes a secondary diagnosis of delirium related to urosepsis. The health care provider prescribes the insertion of an indwelling urinary retention catheter. What nursing action is most important at this time for this client's safety?
Determine if any unsafe behavior patterns exist.
A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client?
Diminished breath sounds
A client who had a lithotripsy for a renal calculus is to be discharged from the hospital. What should the nurse include in the home care instructions?
Drink at least 3 L of fluid daily for four weeks
Which is most important for the nurse to do when providing care to a client who had a transurethral resection of the prostate?
Ensure patency of the indwelling catheter
The nurse is developing a postprocedure plan of care for a client with a continuous bladder irrigation following a transurethral vaporization of the prostate. What should the nurse include in the plan?
Exclude the amount of irrigant instilled from the output
After prostate surgery a client's indwelling catheter and continuous bladder irrigation (CBI) are to be removed. The nurse discusses the procedure with the client. The nurse evaluates that the teaching is understood when the client states, "After the catheter is removed I probably will:
Experience some burning on urination."
A nurse teaches a client who is scheduled for a kidney transplant about the need for immunosuppressive medications. The nurse determines that the client understands the teaching when the client states, "I must take these medications:
For the rest of my life."
The client with emphysema complains of increased shortness of breath and becomes anxious. The health care provider prescribes oxygen at 1 L/minute via nasal cannula. The nurse understands that this prescription is appropriate because:
High concentrations of oxygen eliminate the respiratory drive.
A client is admitted with multiple injuries as a result of an accident. A tracheostomy was performed. While the nurse is caring for this client, the client coughs, expelling the tracheostomy tube onto the bed. What should the nurse's first action be?
Hold the tracheostomy open with a tracheal dilator and call for assistance
What response provides evidence that a client with chronic obstructive pulmonary disease (COPD) understands the nurse's instructions about an appropriate breathing technique?
Holds each breath for a second at the end of inspiration.
What is the most effective way for the nurse to loosen respiratory secretions for a client with an endotracheal tube?
Humidify the prescribed oxygen.
A nurse provides smoking cessation education to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that the client is ready to quit smoking when the client states:
I'll cut back to a half pack a day."
A client will be taking nitrofurantoin (Macrobid) 50 mg orally every evening at home to manage recurrent urinary tract infections. What instructions should the nurse give to the client?
Increase the intake of fluids.
A nurse is caring for a client who experienced a crushing chest injury. A chest tube is inserted. Which observation indicates a desired response to this treatment?
Increased breath sounds
A client with chronic obstructive pulmonary disease has increased hemoglobin and hematocrit levels. The nurse concludes that the altered blood levels are caused by:
Increased erythrocyte production as a result of chronic hypoxia
Which nursing action is important when suctioning the secretions of a client with a tracheostomy?
Initiate suction as the catheter is being withdrawn
A client is admitted to the hospital with a diagnosis of cirrhosis of the liver with ascites. What should the nurse do when preparing this client for a paracentesis?
Instruct the client to empty the bladder
A nurse is assessing a client who is scheduled for a liver biopsy. What assessment finding needs to be reported immediately because it warrants a postponement of the liver biopsy?
International normalized ratio (INR) of 4.0
The pathology report states that a client's urinary calculus is composed of uric acid. The nurse should instruct the client to avoid which food items. Select all that apply
Meat extracts Organ meats
A client with pneumonia now requires use of a nonrebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information?
Mechanical ventilation may be required next.
Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%?
Nonrebreather mask
A client is injured in a motor vehicle accident and admitted for observation. Damage to the bladder is evident. The nurse takes the client's history and concludes that the client is at increased risk of bladder rupture based on the history of:
Not having voided for six hours
A client in a nursing home is diagnosed with urethritis. What should the nurse plan to do before initiating antibiotic therapy prescribed by the health care provider?
Obtain a urine specimen for culture and sensitivity.
A health care provider prescribes daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens?
On awakening
How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes?
Palpate around the tube insertion sites for crepitus.
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which clinical finding supports the nurse's suspicion that the client is developing cor pulmonale?
Peripheral edema
A client who has experienced a fracture of the femur is experiencing respiratory difficulties, and the nurse suspects a pulmonary embolus. Which of these assessment findings is specific to a fat embolism?
Petechiae
In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)?
Positive end-expiratory pressure (PEEP)
A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain?
Presence of a cough and pulmonary secretions
A postmenopausal woman who has cancer of the breast decides to have a lumpectomy followed by chemotherapy. After receiving chemotherapy for several weeks, she says to a nurse at the clinic, "I don't feel well." The nurse reviews the medical record. Based on this information, what does the nurse conclude is the client's priority need?
Preventing infection
The nurse who is teaching the client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing (PLB) is aware that this is beneficial for the client through which mechanism?
Prolonged exhalation to decrease air trapping
A nurse is teaching the importance of annual physical examinations to an adult health and wellness class. The nurse reinforces that it is important for men who are middle-aged and older to have what laboratory test annually?
Prostate-specific antigen (PSA
A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperatively, the nurse should:
Provide a means for the client to write.
A nurse is counseling a woman who had recurrent urinary tract infections. What factor should the nurse explain is the reason why women are at a greater risk than men for contracting a urinary tract infection?
Proximity of the urethra to the anus
A client is receiving an intravenous infusion after a lobectomy for cancer of the lung. The nurse should monitor the client for which complication of intravenous therapy related specifically to postoperative lobectomy?
Pulmonary edema
A client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is:
Pulmonary embolism
When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate?
Remove secretions by suctioning.
A nurse is evaluating a client's understanding of peritoneal dialysis. Which information in the client's response indicates an understanding of the purpose of the procedure?
Remove toxins in addition to other metabolic wastes
When caring for clients who receive anesthesia, the nurse observes the loss of physiological functions during the stages of anesthesia induction. The last function the client loses is:
Respiratory movement
A client returns from a radial neck resection with two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority and requires immediate nursing intervention?
Restlessness and dyspnea
A nurse is caring for clients with various health problems. These problems include scarlet fever, otitis media, bacterial endocarditis, rheumatic fever, and glomerulonephritis. What common factor linking these diseases should the nurse consider?
Result from streptococcal infections that enter via the upper respiratory tract
Immediately after a thoracentesis, a client's right lung collapses. A chest tube is inserted and is attached to a three-chamber closed drainage system. What does the nurse assess about the fluid when the chest tube is functioning properly?
Rises in the tube of the water seal chamber during inspiration.
Immediately after a storm has passed, the nurse is working with a rescue team that is searching for injured people. The nurse finds a victim lying next to a broken natural gas main. The victim is not breathing and is bleeding heavily from a wound on the foot. What should be the nurse's first intervention?
Safely remove the victim from the immediate vicinity.
A nurse teaches a client with chronic renal failure that salt substitutes cannot be used in the diet because:
Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats.
A client is diagnosed as having invasive cancer of the bladder and radiation therapy is scheduled. What should the nurse expect the client to demonstrate that indicates success of radiation therapy?
Shrinkage of the tumor on scanning
The nurse is caring for a client two days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for sputum that is:
Sooty
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance?
Suction as needed
A client is admitted to the hospital with a diagnosis of cancer of the larynx, and a total laryngectomy is scheduled. Which nursing action is most important in the immediate postoperative management of this client?
Suctioning the tracheostomy tube whenever necessary
A client who just returned from surgery reports shortness of breath and chest pain. Which should the nurse initially administer?
Supplemental oxygen
A male client has discharge from his penis. Gonorrhea is suspected. To obtain a specimen for a culture, the nurse should:
Swab the drainage directly from the urethra to obtain a specimen
n teaching a class about sexually transmitted diseases, the nurse discusses signs and symptoms associated with each and effects of delaying treatment. During the discussion, gummas, which are tumors that break and ulcerate, and mental and physical disability were described. Which disease is associated with this process?
Syphyllis
A client is experiencing severe respiratory distress. What response should the nurse expect the client to exhibit?
Tachycardia
A female client has severe abdominal pain. Diagnostic studies reveal a pelvic mass, and the client signs a consent form for removal of the mass. During surgery, the health care provider decides it is necessary to perform a hysterectomy. When the client is informed that her uterus was removed, she sues the hospital, the surgeon, and the nurse. The decision in this case will be based on the fact that:
The client received inadequate information to give consent.
The nurse provides a teaching session related to the severe acute respiratory syndrome (SARS) virus to a group of nursing students. It is appropriate for the nurse to include that, according to evidence-based research, the condition that is related to the SARS virus is:
The common cold
A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care?
The disease process and breathing exercises
A nurse is providing client teaching to a woman who has recurrent urinary tract infections. Which information should the nurse include concerning the reason why women are more susceptible to urinary tract infections than men?
The length of the urethra
A client who is homeless is hospitalized for alcohol withdrawal. When considering the type of personal protective equipment that is needed for the client's care, the nurse recalls that homeless persons are at risk for:
Tuberculosis
After a nephrectomy a client arrives in the postanesthesia care unit in the supine position. Which action should be employed by the nurse to assess the client for signs of hemorrhage?
Turn the client to observe the dressings.
A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcus pneumonia frequently is incontinent of feces and urine and produces copious sputum. When providing care for this client, the nurse's priority is to:
Use gown, mask, and gloves when bathing the client
Diagnostic studies have been prescribed to assess a client's acid-base status. The nurse concludes that the laboratory value that indicates metabolic acidosis is:
Venous serum pH of 7.28
A nurse is caring for a client who had a pneumonectomy. What is the priority nursing assessment?
Ventilatory exchange
The health care provider prescribes an intravenous medication for a client who has been admitted for a chronic obstructive pulmonary disease (COPD) exacerbation. When preparing to initiate an intravenous (IV) line, the nurse applies the tourniquet to select the site. When should the nurse release the tourniquet?
When the needle enters the vein
A client is informed that he has developed a health care-associated upper respiratory tract infection and asks the nurse what this means. How should the nurse reply?
You acquired the infection after being admitted to the hospital."
A client who is diagnosed with sexual dysfunction makes a comment to the nurse, "Well, I guess my sex life is over." What is the most appropriate response by the nurse?
You are concerned about your sex life?"
A health care provider prescribed an indwelling urinary catheter for a client. What catheter should the nurse use to implement this prescription?
c
The nurse is providing postoperative care to a client with lung cancer that had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles can be felt. The nurse describes this assessment finding as:
crepitus
A client presenting with an acute asthma attack is being assessed in the emergency room. The client's spouse reports that the client currently is being treated for an upper respiratory infection. The nurse should understand that the client most likely has which type of asthma?
intrinsic
A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information?
low calcium
An obese client who is mildly hypertensive is hospitalized with a diagnosis of ureteral colic and hematuria. What is the immediate focus of nursing care for this client?
pain
The nurse is caring for a client who recently was diagnosed with urinary phosphate calculi. What should the nurse plan to teach this client to include in the client's diet?
pears
After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus?
pink
A serious train accident occurs in the community. At the scene of the accident a triage nurse is identifying and labeling victims according to triage acuity principles. With what color tag should the nurse label a client who is experiencing respiratory distress?
red
A nurse is reviewing the clinical record of a client with a diagnosis of benign prostatic hyperplasia (BPH). Which test result confirmed the diagnosis?
Biopsy of prostatic tissue
A nurse teaches a client how to perform diaphragmatic breathing. The nurse advises the client to:
Expand the abdomen on inhalation
A client is admitted to the intensive care unit with acute pulmonary edema. Which rapidly acting intravenous diuretic should the nurse anticipate will be prescribed?
Furosemide (Lasix)
In addition to Pneumocystis jiroveci, a client with acquired immunodeficiency syndrome (AIDS) also has an ulcer 4 cm in diameter on the leg. Considering the client's total health status, the most critical concern is:
Gas exchange
During the assessment of a client who was admitted to the hospital because of a productive cough, fever, and chills, the nurse percusses an area of dullness over the right posterior lower lobe of the lung. The nurse determines that the client's signs and symptoms may be indicative of:
Pneumonia.
A nurse is caring for a client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve?
Raising mucous secretions from the chest
A client is taught how to change the dressing and how to care for a recently inserted nephrostomy tube. On the day of discharge the client states, "I hope I can handle all this at home; it's a lot to remember." The best response by the nurse is:
You seem to be nervous about going home."
A client is suspected of having late-stage (tertiary) syphilis. When obtaining a health history, the nurse determines that the client statement that most supports this diagnosis is:
"I'm having trouble keeping my balance."
A client with the diagnosis of osteogenic sarcoma has metastasis to the lung. Which client statement about the concept of metastasis indicates a need for further instruction?
"I'm upset to know that the tumor may metastasize to my bones."
A client who has had a transurethral prostatectomy (TURP) experiences dribbling after the indwelling catheter is removed. To address this problem, an appropriate nursing response is:
"Increase your fluid intake and urinate at regular intervals."
A client is admitted with a diagnosis of torsion of the testes. How should the nurse respond when the client asks, "Why do I have to have surgery right now?"
"Irreversible damage occurs after a few hours."
On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, the nurse most likely will identify
Deep and rapid respirations
A client with a history of closed-angle glaucoma is scheduled for abdominal surgery. Because the client is extremely anxious, surgery is to be performed under general anesthesia. What should the nurse teach the client to do to prevent respiratory complications postoperatively?
Deep-breathing techniques
Following surgery in the inguinal area, the client complains of pain on the right side of the chest, becomes dyspneic, and begins to cough violently. The nurse suspects that a pulmonary embolus has occurred. What is the priority nursing action?
Elevate the head of the bed
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/hour. One hour later, the client begins screaming, "I can't breathe!" How should the nurse respond?
Elevate the head of the client's bed and obtain vital signs
Twenty-four hours after a penile implant the client's scrotum is edematous and painful. The nurse should:
Elevate the scrotum using a soft support
Polycythemia frequently is associated with chronic obstructive pulmonary disease (COPD). When assessing for this complication, the nurse should monitor for:
Elevated hemoglobin
The nurse develops a plan of care related to a coughing and deep breathing regimen for a client who has had a pneumonectomy. The plan should include that, postoperatively, the client should cough and deep breathe:
Every hour for the first 24 hours and then every 2 hours
A client who had a transurethral resection of the prostate is transferred to the postanesthesia care unit with an IV and a urinary retention catheter. For which major complication is it most important for the nurse to assess during the immediate postoperative period?
Hemorrhage
A client who had thoracic surgery complains of pain at the incision site when coughing and deep breathing. What action should the nurse take?
Instruct the client to splint the wound with a pillow when coughing
A client with ascites is scheduled to have a paracentesis. What should the nurse include in the plan of care?
Instruct the client to urinate before the procedure
The nurse is caring for a client with ureteral colic. To prevent the development of renal calculi in the future, the client's plan of care should include
Instructing the client to drink 8 to 10 glasses of water daily
A client experiences difficulty in voiding after an indwelling urinary catheter is removed. The nurse determines that this difficulty most likely is related to:
Interruption in previous voiding habits
A client with tuberculosis asks the nurse why vitamin B6 (pyridoxine) is given with isoniazid (INH). What explanation should the nurse provide?
Isoniazid interferes with the synthesis of this vitamin."
The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. For which clinical indicator should the nurse assess first?
Mental confusion
A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism?
Obese client with leg trauma
A nurse is caring for an older bedridden male client who is incontinent of urine. What nursing intervention is the most satisfactory initial approach to managing urinary incontinence?
Offering the urinal regularly
A male client reports dysuria, nocturia, and difficulty starting the urinary stream. A cystoscopy and biopsy of the prostate gland have been scheduled. After the procedure the client reports an inability to void. The nurse should:
Palpate above the pubic symphysis
A client is admitted to the hospital with a diagnosis of emphysema. What should the nurse include when teaching the client breathing exercises?
Perform diaphragmatic exercises to improve contraction of the diaphragm
A nurse is caring for a client with a diagnosis of cancer of the prostate. The nurse should teach the client that which serum level will be monitored throughout the course of the disease?
Prostate-specific antigen (PSA)
A client with ascites has a paracentesis, and 1500 mL of fluid is removed. For what immediate response is it most important for the nurse to monitor?
Rapid, thready pulse
A client admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD) has received a prescription for a medication that is delivered via a nebulizer. When teaching about use of the nebulizer, the nurse should teach the client to:
Seal the lips around the mouthpiece and breathe in and out taking slow, deep breaths
A nurse is caring for a client with glomerulonephritis. What should the nurse instruct the client to do to prevent recurrent attacks?
Seek early treatment for respiratory tract infections.
A client is transferred from the postanesthesia care unit to the intensive care unit after a radical neck dissection. In what position should the nurse place the client to facilitate respirations and promote comfort?
Semi-Fowler
A client with tuberculosis asks the nurse how long chemotherapy will be continued. The nurse's most accurate reply is:
Six to twelve months
A client with a history of excessive alcohol use develops hepatic portal hypertension and an elevated serum aldosterone level. For which complications should the nurse assess this client?
Sodium retention and fluid accumulation
A client has a persistent productive cough that becomes blood tinged. A needle biopsy is scheduled. The client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which is the most appropriate response by the nurse?
Tell me more about the conversation you had with your health care provider."
A nurse is caring for a client with acute kidney failure who is receiving a protein restricted diet. The client asks why this diet is necessary. What information should the nurse include in a response to the client's questions?
This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys.
When assessing a client during peritoneal dialysis, a nurse observes that drainage of the dialysate from the peritoneal cavity has ceased before the required volume has returned. What should the nurse instruct the client to do?
Turn from side to side
A nurse provides teaching to a client who is scheduled to begin peritoneal dialysis. The instructions include information about what the client should do if drainage of dialysate from the peritoneal cavity ceases before the required amount has drained out. The nurse evaluates that the teaching has been effective when the client states, "If that happens, I will:
Turn from side to side."
Before signing a consent form for a total laryngectomy, a client asks, "Because part of my throat will be taken out and I will breathe through a hole in my neck, will I be able to talk like I did before I had the surgery?" Which is the nurse's best response?
You seem very concerned. Tell me what you know about your surgery."
A client is admitted to the hospital for acute gastritis and ascites secondary to alcoholism and cirrhosis. It is most important for the nurse to assess this client for:
blood in the stool
A client with acute kidney failure states, "Why am I twitching and my fingers and toes tingling?" The nurse should respond, "This is caused by:
calcium depletion.
Cancer of the lung is confirmed in a client who is a heavy smoker, and a lobectomy is performed. After the surgery the nurse identifies puffiness of the tissue surrounding the dressing and the tissue feels spongy and crackles when palpated. Which term should the nurse document in the medical record when describing this assessment?
crepitus
A client with acute glomerulonephritis reports feeling thirsty. What should the nurse offer the client?
hard candy
A client with acute kidney failure is to receive peritoneal dialysis and asks why the procedure is necessary. The nurse's best response is, "It:
helps perform some of the work usually done by the kidneys."
A client who just had a kidney transplant is transferred from the postanesthesia care unit (PACU) to the intensive care unit (ICU). The nurse in the ICU should monitor the client's urinary output every:
hour
A nurse is caring for a client who was admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease and is receiving oxygen at 2 L via nasal cannula. What is the primary focus of therapy when caring for this client?
improving ventilation
At 10 AM the nurse hangs a 1000 mL bag of D5W with 20 mEq of potassium chloride to be administered at 80 mL/hr. At noon the health care provider prescribes a stat infusion of an intravenous (IV) antibiotic of 100 mL to be administered via piggyback over one hour. How much later than expected will it take the primary bag to empty if the nurse interrupts the primary infusion to use the circulatory access for the secondary infusion of the antibiotic?
one hour
A client who is 5 feet, 8 inches tall and weighs 220 pounds is admitted to the hospital with ureteral colic, blood in the urine, and a blood pressure of 150/90. The immediate objective of nursing care for this client is to decrease:
pain
A nurse is caring for a male client who is scheduled for a dilation of the urethra. Which structure surrounding the male urethra should the nurse include in a teaching program when explaining the procedure?
prostate gland
The nurse is reviewing the client's health history. With which diagnosis is a client most likely to exhibit hemoptysis?
tuberculosis
A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery?
"An indwelling urinary catheter is required for at least a day."
A nurse is preparing a client for discharge from the emergency department. Which client statement provides evidence that the client understands the instructions for the prescribed high-dose ampicillin?
"I must increase my intake of fluids while taking this medication."
A diet that contains restricted amounts of protein, sodium, and potassium has been prescribed for a client with end-stage renal disease who is receiving dialysis. The nurse is providing dietary instructions and evaluates that the teaching is effective when the client says:
"I should avoid using salt substitutes."
A client with renal colic is scheduled for extracorporeal shock-wave lithotripsy. The night before the procedure, the client puts the call light on frequently and has many demands. Which would be an appropriate statement for the nurse to make?
"You are facing a new experience tomorrow; tell me what concerns you have."
A nurse is reviewing the arterial blood gas results of several clients. Which client's arterial blood gas result indicates metabolic acidosis?
A
The nurse is caring for a client whose arterial blood gases (ABGs) values are: Po2 89 mm Hg, Pco2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing:
Acid-base balance
An older adult client is demonstrating mild confusion after surgical repair of a hernia. What should the nurse do to provide for this client's safety?
Activate the position-sensitive bed alarm.
A client presents to the emergency room with coughing and sudden wheezing. The nurse notes the client is progressing quickly into respiratory distress. The nurse identifies that the client is experiencing:
Acute asthma attack.
A client is admitted to the hospital from the emergency department with a diagnosis of urolithiasis. The nurse reviews the client's clinical record and performs an admission assessment. What is the priority nursing
Administer the prescribed morphine.
The nurse is caring for a 75-year-old client who had radical head and neck surgery. Thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. The nurse should:
Administer the prescribed oxygen
A client is admitted to the intensive care unit with a diagnosis of adult respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client?
Altered mental status
When clients develop respiratory alkalosis, the nurse expects lab values to reflect:
An elevated pH, decreased Pco2
A nurse is a preceptor for an orientee (newly hired nurse). The orientee is providing postoperative care to a client who recently returned from a laryngoscopy. The orientee reminds the client not to eat or drink anything until instructed to do so. The preceptor informs the orientee that the instructions given to the client were:
Appropriate; oral intake after the procedure may result in aspiration
A client with a malignant parotid tumor is treated aggressively with radiation therapy and surgery. Postsurgical arterial blood gas results are: pH 7.32, Pco2 53 mm Hg,and HCO3 25 mEq. The nurse should take which action?
Ask the client to cough forcefully and take deep breaths
A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do?
Assess the client's pain before increasing the dose of morphine.
A client's respiratory status deteriorates, and endotracheal intubation and positive pressure ventilation are instituted. What is the nurse's most immediate intervention at this time?
Assess the client's response to the interventions.
The nurse reviews the medical records of four male clients and concludes that the client that is at highest risk of developing prostate cancer is the:
Black 55-year-old
A nurse is instructing a client to use an incentive spirometer. What client action indicates the need for further instruction?
Blowing vigorously into the mouthpiece
During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take?
Check the tube to ensure that it is not kinked.
A client has been admitted for an upper respiratory tract infection secondary to chronic obstructive pulmonary disease (COPD). The nurse should expect which findings when auscultating the client's breath sounds?
Coarse crackles
A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. A commonality of the various stationary chest tube drainage systems is that the first chamber is designed to:
Collect drainage
A client arrives at a health clinic reporting hematuria, frequency, urgency, and pain on urination. What does the nurse suspect is the cause of these signs and symptoms?
Cystitis
The nurse is providing postoperative care eight hours after a client had a total cystectomy and the formation of an ileal conduit. What assessment finding should be reported immediately?
Dusky-colored stoma
Which intervention should the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma?
Encourage coughing and deep breathing.
The nurse assists with a client's yearly physical examination. After the examination is completed, the client is diagnosed with tuberculosis. Which action best reflects appropriate epidemiological follow-up?
Encouraging close family members, friends, and coworkers of the client to have a skin test
A nurse is caring for a client who had an open abdominal cholecystectomy because of biliary colic. Which nursing action is most important during the postoperative period?
Encouraging coughing and deep breathing
A client has a left pneumonectomy. Which nursing intervention is critical when the client regains consciousness in the postanesthesia care unit?
Encouraging deep breathing
The primary responsibility of a nurse when caring for a client with a chest tube attached to a three-chamber underwater-seal drainage system is to:
Ensure maintenance of the closed system
A client with a 30-year history of smoking has several episodes of blood in the sputum. A bronchoscopy with a lung biopsy is performed. After the procedure, the most important nursing intervention is to:
Ensure nothing by mouth (NPO) until the gag reflex returns
A client is scheduled for a transurethral needle ablation (TUNA) of the prostate with a continuous bladder irrigation. The client will be discharged from the outpatient unit with a urinary retention catheter in place. What is most important for the nurse to teach the client before discharge?
Ensuring urine flows from the catheter
After a laryngectomy a client is concerned about improving the ability to communicate. What topic should the nurse include in a teaching plan for the client?
Esophageal speech
After a laryngectomy is scheduled, the most important factor for the nurse to include in the preoperative teaching plan is:
Establishing a means for communicating postoperatively
A client returns to the unit fully awake after a bronchoscopy and biopsy. What is the most important nursing intervention?
Evaluate the presence of a gag reflex.
A client states that the health care provider said the tidal volume (TV) is slightly diminished and asks the nurse what this means. Which explanation should the nurse provide about the volume of air being measured to determine tidal volume?
Exhaled after there is a normal inspiration
A client who is taking rifampin (Rifadin) tells the nurse, "My urine looks orange." What action should the nurse take?
Explain this is expected
A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). The pathophysiologic changes associated with ARDS progress through expected phases. What phase is characterized by signs of pulmonary edema and atelectasis?
Exudative
A client with chronic kidney disease is scheduled to begin peritoneal dialysis. When discussing the procedure, the nurse explains that the purpose of the dialysis is to:
Help do some of the work usually done by the kidneys
A community health nurse is educating a client who is interested in discontinuing cigarette smoking. What should the teaching plan include?
Helping the client set a date to stop smoking
A client is admitted to the hospital with a ureteral calculus. The nurse expects what urinary clinical findings?
Hematuria with sharp pain when voiding
A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a common early sign of laryngeal cancer for which the nurse should assess this client?
Hoarseness
A client is diagnosed as having kidney failure. During the oliguric phase the nurse should assess the client for:
Hyperkalemia
A nurse is caring for a client with a diagnosis of chronic kidney failure who has just been told by the health care provider that hemodialysis is necessary. Which clinical manifestation indicates the need for hemodialysis?
Hyperkalemia
Which is the most serious complication for which the nurse must monitor a client with kidney failure?
Hyperkalemia
A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube?
Hyperoxygenate with 100% oxygen before and after suctioning.
A nurse is preparing to discharge a client who had a transurethral prostatectomy for benign prostatic hyperplasia. The nurse evaluates that the client understands the discharge teaching when the client states:
I will use stool softeners regularly for the next one to two months."
A nurse is teaching Hands Only Basic Life Support for adults in the community. What should the rescuer do first after determining that the person is not responding and the emergency medical system has been activated?
Identify the absence of pulse.
A nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. What information is most significant to include?
Importance of meticulous oral hygiene
A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason why metabolic acidosis develops with kidney failure?
Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate
After abdominal surgery a goal is to have the client achieve alveolar expansion. The nurse determines that this goal is most effectively achieved by:
Incentive spirometry.
A nurse is caring for a client who is scheduled for cystoscopy. What should the nurse include in the client's postprocedure teaching plan?
Increase fluid intake for three to four days postoperatively
The nurse is providing education to a client who is scheduled for a transurethral microwave thermotherapy (TUMT) of the prostate. What would be appropriate to include in the postoperative teaching plan?
Initially, an indwelling urinary catheter will be in place.
The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. The type of respirations that the nurse expects the client to exhibit is:
Kussmaul's breathing
A firefighter is admitted to the emergency department with severe dermal and inhalation burns. On assessment, a nurse identifies tachycardia, tachypnea, and dyspnea. What term should the nurse document in the medical record when the following is heard on auscultation of the lungs of this client?
Listen to the audio Stridor
A nurse is caring for a client who had a nephrectomy because of cancer of the kidney. Which factor will influence the client's ability to deep breathe and cough postoperatively?
Location of the surgical incision
A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, what response does the nurse expect?
Metabolic acidosis
As a result of pulmonary tuberculosis, a client has a decreased surface area for gas exchange in the lungs. Which physiologic process does the nurse consider will be affected as a result?
Molecular diffusion
After administering a loop diuretic, a nurse monitors the client for increased urine output. What principle explains the secondary water loss (diuresis) of a loop diuretic?
Osmosis
A client is at high risk for developing ascites because of cirrhosis of the liver. How should the nurse assess for the presence of ascites?
Percuss the client's abdomen and listen for dull sounds.
The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation in place. The purpose of this irrigation is to:
Prevent the development of clots in the bladder
A client with a pneumothorax has a chest tube inserted and attached to a closed-chest drainage system. The client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" The nurse explains that the water:
Prevents reflux of air back into the chest
Before discharge, the nurse is planning to teach the client with emphysema pursed-lip breathing. The nurse should instruct the client that the purpose of pursed-lip breathing is to:
Promote elimination of CO2.
What is the most basic method the nurse can use when encouraging hospitalized clients to void?
Providing privacy
A client has a heminephrectomy and returns from the postanesthesia care unit with a nephrostomy tube and an indwelling urinary catheter. The client's urinary output is 50 mL/hr. What is the nurse's next action?
Record the findings.
What should the nurse expect when assessing a client with pleural effusion?
Reduced or absent breath sounds at the base of the lung
A client has a closed chest drainage system in place. To determine the amount of chest tube drainage, the nurse should:
Refer to the date and time markings on the outside of the collection chamber
A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish?
Remove the air that is present in the intrapleural space
The client receiving peritoneal dialysis suddenly complains of abdominal distention and the nurse observes a decrease in dialysate output. What is the priority nursing action(s)?
Reposition the client and assess the abdominal cavity.
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco2 of 60. These blood gases require nursing attention because they indicate:
Respiratory acidosis
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a Pco2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing?
Respiratory acidosis
A client, complaining of fatigue, is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). To prevent fatigue, the nurse should:
Schedule nursing activities to allow for rest
A client returns from surgery after a total laryngectomy with a laryngectomy tube in the permanent stoma. In which position should the nurse place this client to facilitate respirations and promote comfort?
Semi-Fowler position
A nurse is providing postoperative care to a client who had a kidney transplant. What assessment is the best indicator of the functioning of the newly transplanted kidney?
Serum creatinine
When providing discharge teaching for a young female client who had a pneumothorax, it is important that the nurse include the signs and symptoms of a recurring pneumothorax. What is the most important symptom that the nurse should teach the client to report to the healthcare provider?
Severe shortness of breath
A client who is to begin continuous ambulatory peritoneal dialysis (CAPD) asks the nurse what this treatment entails. What information should the nurse include in the explanation?
The peritoneal membrane allows passage of toxins into the dialysate.
The nurse provides preoperative education to a client with extensive cancer of the upper right lobe of the lung who is scheduled for a lobectomy. The nurse concludes that the teaching was effective when the client states,
The remaining lung tissue will fill in the empty space. I will have chest tubes to help with drainage after surgery."
To prepare for hemodialysis, a client with end-stage kidney disease is scheduled for surgery, specifically the creation of an internal arteriovenous fistula in one arm and placement of an external arteriovenous shunt in the other arm. The shunt will be used until the fistula heals. When considering the differences between the two devices, the nurse recalls that:
The shunt is more subject to the complications of hemorrhage, clotting, and infection than the fistula is.
A client who is recovering from deep partial-thickness burns develops chills, fever, flank pain, and malaise. The health care provider makes a tentative diagnosis of urinary tract infection. Which diagnostic tests should the nurse expect the health care provider to prescribe to confirm this diagnosis?
Urinalysis and urine culture and sensitivity
chloride. What assessment should be brought to the health care provider's attention before administration of the intravenous (IV) line?
Urinary output of 200 mL during the previous 8 hours
The nurse is caring for a client that weighs 90 kilograms. The nurse is determining the client's response to fluid replacement therapy. The clinical finding that indicates adequate tissue perfusion to vital organs is:
Urinary output of 60 mL/hr
The nurse is caring for a client with cancer of the lung who is considering the biological therapy (e.g., monoclonal antibodies, interferon) that has been recommended in the client's treatment plan. The nurse recalls that this therapy is:
Used as an adjuvant therapy with other therapies
The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right sided heart failure after discharge. The nurse instructs the client to assess for
Weight gain
A nurse administers trimethoprim-sulfamethoxazole (Bactrim) to a client diagnosed with a urinary tract infection. What should the nurse monitor to determine the therapeutic effectiveness of the drug?
White blood cell (WBC) count
A client with a diagnosis of tuberculosis is receiving isoniazid (INH) as part of a chemotherapy protocol. The nurse assesses the client for adverse responses to the medication. The nurse determines that prompt intervention is needed for which client response?
Yellow sclera
A client is receiving morphine sulfate (MS Contin) for severe metastatic bone pain. To prevent complications from a common, serious side effect of morphine, the nurse should:
assess for altered breathing patterns
A person's bathrobe ignites while the individual is cooking in the kitchen on a gas stove. What is the priority intervention after the flames are extinguished?
assess the person's breathing
client with cancer of the lung says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse conclude the client is in?
bargaining
While conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)?
barrel chest
An older adult comes for an annual physical and tells the nurse, "I had three respiratory infections last year. How can I prevent this from happening again?" What is the nurse's best response?
"Avoid putting your hands near your nose and mouth."
A client with a chest tube is to be transported via a stretcher. When transporting the client, the nurse should keep the:
Collection device below the level of the client's chest.
A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiological response?
Depression in the respiratory center
A health care provider prescribes oxygen given in low concentration rather than in high concentration to a client with chronic obstructive pulmonary disease (COPD). What does this prevent?
Depression of the respiratory center
A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client?
Give prescribed drugs to promote bronchiolar dilation.
A health care provider prescribes oropharyngeal suctioning as needed for a client in a coma. Which assessment made by the nurse indicates the need for suctioning?
Gurgling sounds with each breath
A nurse is caring for a client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. What complication is the nurse trying to prevent?
Respiratory acidosis
