UNRS 107 Quiz 2_Rationale - ATI Quiz #2A

21. A nurse is preparing to administer dextromethorphan 30 mg PO. The amount available is dextromethorphan oral liquid 7.5 mg/5mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

20 mL

27. A nurse is preparing to administer albuterol syrup 1.6 mg PO tid. Available is albuterol 2 mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

4 mL

13. A nurse is preparing to suction a client who has a tracheostomy. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) A. Adjust the suction. B. Apply suction while rotating the catheter. C. Don sterile gloves. D. Check the function of the suction catheter. E. Insert the catheter without suction. F. Hyperoxygenate the client. Assess for secretion clearance.

A. Adjust the suction. C. Don sterile gloves. D. Check the function of the suction catheter. F. Hyperoxygenate the client. E. Insert the catheter without suction. B. Apply suction while rotating the catheter. Assess for secretion clearance.

16. A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? A. Attach a humidifier bottle to the base of the flow meter. B. Remove the nasal cannula while the client eats. C. Secure the oxygen tubing to the bed sheet near the client's head. D. Apply petroleum jelly to the nares as needed to soothe mucous membranes.

A. Attach a humidifier bottle to the base of the flow meter. Rationale: Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4 L/min via nasal cannula.

18. A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear? A. Loud, scratchy sounds B. Squeaky, musical sounds C. Popping sounds D. Snoring sounds

A. Loud, scratchy sounds Rationale: Loud, scratchy sounds caused by inflammation of the pleura are a manifestation of pleurisy.

6. As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure? A. Remove all metal necklaces. B. Take several shallow breaths during the procedure. C. Do not eat or drink anything the morning of the test. D. Expect minor discomfort after the procedure.

A. Remove all metal necklaces. Rationale: Metal objects block visualization of body structures and tissues, thus the client must remove them.

7. A nurse is teaching a client about taking diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect of this medication? A. Sedation B. Constipation C. Hypertension D. Bradycardia.

A. Sedation Rationale: Diphenhydramine can cause sedation. It is used to treat rhinitis, allergies, and insomnia.

4. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse should take? A. Observe the client before taking further action. B. Perform the Heimlich maneuver. C. Assist the client to the floor and begin mouth-to-mouth resuscitation. D. Slap the client on the back several times.

B. Perform the Heimlich maneuver. Rationale: The client cannot talk, coughs only once, and is demonstrating the universal choking sign: grasping at the throat with the hands. Choking requires immediate intervention. The Heimlich maneuver is the most effective method for clearing the obstruction in the airway of a choking person.

14. A nurse is dining at a restaurant when a woman begins to scream that her partner is choking. Which of the following actions should the nurse take? A. Instruct the woman to call 911. B. Ask the partner if he can speak. C. Use the jaw-thrust maneuver. D. Perform chest compressions.

B. Ask the partner if he can speak. Rationale: Before intervening, the nurse should determine if the partner's airway is blocked. Therefore, the nurse should ask the partner if he can speak. If he can speak, breathe, or cough, air is moving through his airway.

29. A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information should the nurse include in the teaching? A. Raise the affected extremity above the level of the heart. B. Immobilize the affected extremity with a splint. C. Apply ice to the bite area. D. Apply a tourniquet to the affected extremity.

B. Immobilize the affected extremity with a splint. Rationale: Immobilizing the client's affected extremity with a splint will limit the spread of the venom in the circulatory system.

5. A community health nurse is conducting an educational program on various environmental pollutants. The nurse should emphasize that clients who have which of the following disorders are especially vulnerable to ozone effects? A. Osteoarthritis B. Basal cell carcinoma C. Asthma D. Hypothyroidism

C. Asthma Rationale: The ozone exerts its primary adverse effects on the respiratory system, reducing lung function and increasing the risk of respiratory infection. Clients who have respiratory disorders, such as asthma and COPD, are especially vulnerable.

11. A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? A. Encourage the client to ambulate frequently. B. Encourage coughing and deep breathing. C. Encourage the client to increase fluid intake. D. Encourage regular use of the incentive spirometer.

C. Encourage the client to increase fluid intake. Rationale: Increasing fluid intake to1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

28. A nurse caring for a client who is vomiting. Which of the following actions should the nurse take first? A. Provide the client with an emesis basin. B. Notify housekeeping. C. Prevent the client from aspirating. D. Administer an antiemetic to the client.

C. Prevent the client from aspirating. Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines the priority action is to prevent the client from aspiration by turning the client to his side and suctioning his airway.

22. A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? A. A client who has scabies B. A client who has pertussis C. A client who has streptococcal pharyngitis D. A client who has measles

D. A client who has measles Rationale: A client who has measles requires airborne precautions as well as a negative pressure room.

23. A nurse is teaching a client who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the client to use to abort an acute asthma attack? A. Beclomethasone B. Salmeterol C. Formoterol D. Albuterol

D. Albuterol Rationale: Albuterol is an inhaled short-acting beta2 agonist (beta2-adrenergic agonist) used as a rescue medication to relieve an acute asthma attack. Albuterol dilates the airways, decreases wheezing, and improves oxygenation.

8. A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain that this type of medication has which of the following actions? A. Reduces inflammation B. Suppresses the urge to cough C. Dries mucous membranes D. Stimulates secretions

D. Stimulates secretions Rationale: Expectorants act by increasing secretions to improve a cough's productivity.

2. A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? A. Suction two to three times with a 60-second pause between passes B. Perform chest physiotherapy prior to suctioning. C. Lubricate the suction catheter tip with sterile saline. D. Hyperventilate the client on 100% oxygen prior to suctioning.

A. Suction two to three times with a 60-second pause between passes. Rationale: Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.

10. A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? A. Repeat auscultation after asking the client to breathe deeply and cough. B. Instruct the client to limit fluid intake to less than 2,000 mL/day. C. Prepare to administer antibiotics. D. Place the client on bed rest in semi-Fowler's position.

A. Repeat auscultation after asking the client to breathe deeply and cough. Rationale: Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a cough.

25. A nurse is providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching? A. Shake the inhaler for 3 to 5 seconds. B. Rinse the mouth with mouthwash after inhaling the medication. C. Wait 2 min between inhalations. D. Press down twice on the MDI canister.

A. Shake the inhaler for 3 to 5 seconds. Rationale: After fully inserting the canister into the inhaler, the client should shake it vigorously for 3 to 5 seconds to make sure he mixes the medication thoroughly.

1. A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take? A. Tell the client to blow her nose gently before the instillation. B. Assist the client to a side-lying position. C. Hold the dropper 2 cm (1 in) above the naris. D. Instruct the client to stay in the same position for 2 min.

A. Tell the client to blow her nose gently before the instillation. Rationale: Prior to instillation, the nurse should instruct the client to blow her nose gently. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication

30. Complete the following sentence by using the list of options. Rationale: Dropdown 1Place the client in high-Fowler's position is correct. When using the airway breathing and circulation approach to client care, the nurse should first place the client in high-Fowler's position to promote gas exchange.Obtain a doppler ultrasound, administer an anticoagulant, and obtain ABGs are incorrect. The nurse might obtain a doppler ultrasound at some point to detect presence of a venous thromboembolism; however, there is another the action the nurse should take first. The nurse might need to administer an anticoagulant at some point, but at this time there is another action that the nurse should take first. The nurse might need to obtain ABGs at some point: however, there is another action that the nurse should take first.Dropdown 2 Obtaining IV access is correct. After placing the client in high-Fowler's position, the nurse

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19. A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching? A. "I will inhale slowly through pursed lips to help me breathe better." B. "I will avoid getting a flu shot." C. "I will follow a daily diet high in calories and protein." D. "I will lie on my stomach to practice abdominal breathing every day."

C. "I will follow a daily diet high in calories and protein." Rationale: Clients who have emphysema have greater-than-usual nutritional requirements for calories and protein and often need nutritional supplements between meals.

12. A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Verify the oxygen flow rate every other day. B. Check the cannula position on a regular basis. C. Check the tops of the ears for skin breakdown. D. Post "no smoking" signs in a prominent location in the home. E. Apply petroleum ointment to nares if they become dry and irritated.

B. Check the cannula position on a regular basis. C. Check the tops of the ears for skin breakdown. D. Post "no smoking" signs in a prominent location in the home. Rationale: Verify the oxygen flow rate every other day is incorrect. The rate of oxygen flow should be checked daily.Check the cannula position on a regular basis is correct. The position of the nasal cannula should be verified every 8 hours or more often if needed.Check the tops of the ears for skin breakdown is correct. The tops of the ears, the nares and the nasal mucous membranes should be assessed regularly for skin breakdown.Post "no smoking" signs in a prominent location in the home is correct. The family is instructed to post "no smoking" signs in a prominent location in the home because oxygen increases the risk of fire injuries.Apply petroleum ointment to nares if they become dry and irritated is incorrect. Protecting the nares is important, but the client should use a water-based lubricant or saline nasal spray to reduce dryness and irritation. Oxygen has a high combustion potential, and petroleum products are combustible.

24. A nurse is planning care for a client who has terminal cancer and has a prescription for morphine. Which of the following interventions should the nurse include in the plan of care? A. Instruct the client to take diphenoxylate/atropine 5 mg PO twice a day. B. Instruct the client to actively cough to prevent a buildup of secretions in the airway. C. Instruct the client to stop taking the morphine if itching develops. D. Instruct the client to keep room lights dim during waking hours.

B. Instruct the client to actively cough to prevent a buildup of secretions in the airway. Rationale: Morphine acts on the medulla to suppress cough. The nurse should teach the client to actively cough to prevent a buildup of secretions in the airway.

20. A nurse is assessing a client who has chronic bronchitis. Which of the following percussion sounds should the nurse expect? A. Dullness B. Resonance C. Tympany D. Flatness

B. Resonance Rationale: Resonance characterizes chronic bronchitis. It is a loud, low-pitched sound of long duration.

26. A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply.) A. The medication will stimulate flow of mucus. B. The medication will prevent wheezing. C. The medication will open the airways. D. The medication will reduce inflammation. E. The medication will decrease coughing episodes.

B. The medication will prevent wheezing. C. The medication will open the airways. E. The medication will decrease coughing episodes. Rationale: The medication will stimulate flow of mucus is incorrect. Expectorants, such as guaifenesin, stimulate the flow of mucous to produce a productive cough. Asthma is characterized by bronchoconstriction, airway edema, and increased mucus production. Albuterol relaxes the airways, allowing for expectoration of mucus. The medication will prevent wheezing is correct. Albuterol is used to prevent or treat wheezing. The medication will open the airways is correct. Albuterol promotes bronchodilation. The primary purpose is to provide rapid relief of bronchoconstriction, thus opening the airway and improving oxygenation. The medication will reduce inflammation is incorrect. Albuterol does not reduce inflammation. Glucocorticoid medications reduce inflammation. The medication will decrease coughing episodes is correct. Coughing is often an early indicator of bronchospasm. Albuterol provides a rapid response to relax smooth muscle and reduce bronchoconstriction, which will decrease coughing.

9. A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? A. Serosanguineous drainage from the puncture site B. Discomfort at the puncture site C. Increased heart rate D. Decreased temperature

C. Increased heart rate Rationale: Clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal content shift after the aspiration of a large amount of fluid from the client's pleural space. Therefore, the client may experience an increase in heart and respiratory rate, along with coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require notification of the provider immediately.

3. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as often as possible B. Administering oxygen via nasal cannula at 2 L/min C. Helping the client select a low-salt diet D. Encouraging the client to drink 2 to 3 L of water daily

D. Encouraging the client to drink 2 to 3 L of water daily Rationale: COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.

15. A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant? A. Remove the hood every hour for 10 min to facilitate bonding. B. Insert an orogastric tube for decompression of the stomach. C. Place the newborn in Trendelenburg position. D. Maintain oxygen saturations between 93% to 95%.

D. Maintain oxygen saturations between 93% to 95%. Rationale: Rates of retinopathy of prematurity and bronchopulmonary dysplasia in preterm newborns are reduced if oxygen saturations are maintained between 93% and 95%.

17. A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? A. Crackles B. Rhonch C. Stridor D. Wheezes

D. Wheezes Rationale: Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope.