Week 2 Principals 4.0
Alcohol withdrawal
A client with a history of heavy drinking is brought to a psychiatric facility in a stupor. Two days after admission the client is confused, disoriented, and delusional. The nurse concludes that the client may be developing which of the following complications? Answer Options * Gastrointestinal bleed Hypoglycemic event Alcohol withdrawal Myocardial infarction
Lung auscultation and pulse oximetry
A client with asthma presents to the unit and complains of shortness of breath and wheezing. Which of the following are key assessments for determining the adequacy of ventilation? Answer Options * Absence of pallor and respiratory rate Thoracic palpation and percussion Chest X-Ray result Lung auscultation and pulse oximetry
Assess for bleeding behind the back.
A client with chronic Hepatitis C virus (HCV) is scheduled for a liver biopsy. Which intervention should the nurse perform after the procedure? Answer Options * Progress activity as soon as possible. Assess for bleeding behind the back. Place the client in a left lateral position. Monitor the respirations every 4 hours.
Encourage deep breathing as tolerated.
A client who received general anesthesia has just returned from the operating room. Which action should the nurse take to help eliminate the effects of general anesthesia? Answer Options * Restart oral fluids as soon as possible. Encourage deep breathing as tolerated. Have the client ambulate to expel the gas. Provide full body passive range of motion.
Administer oxygen 2 L/min via nasal cannula
A client with chronic obstructive pulmonary disease presents to emergency department triage gasping for air. The client's oxygen saturation is 89% on room air, heart rate 118 beats/min. Which action should the nurse perform immediately? Answer Options * Elevate the head of the bed to 20 degrees Administer oxygen 2 L/min via nasal cannula Call respiratory to obtain an arterial blood gas Monitor the vital signs until the client is stable
Ask the client if you can remove the fingernail polish
A client's oxygen saturation is 86%. The nurse notes the client has nail polish on the fingernails. Which action by the nurse is a priority? Answer Options * Notify the physician to obtain an arterial blood gas Relocate the oxygen saturation probe to the great toe Ask the client if you can remove the fingernail polish Document the oxygen saturation findings in the chart
Stop the procedure and give oxygen
A nurse is suctioning secretions through a client's endotracheal tube. The nurse detects a significant drop in the client's heart rate. Which action should the nurse take next? Answer Options * Quickly finish the suctioning procedure Limit each suctioning pass to 15 seconds Notify the healthcare provider immediately Stop the procedure and give oxygen
Medications tend to be more potent and the effects last longer in the elderly.
A physician orders lorazepam (Ativan) for an elderly client who is anxious. The ordered dose is one-half the regular adult dose. For which reason is this elderly client prescribed this dosage of lorazepam (Ativan)? Answer Options * The medication dose should be based on the client's average weight. Taking only half the dose will reduce cost to the client's insurance company. Medications tend to be more potent and the effects last longer in the elderly. Oral medications should be given in small frequent doses for the elderly.
Cyanosis
A student nurse is assessing a patient who has a new onset of bronchitis. The nurse observes that the respirations are uneven and labored and the patient complains of dyspnea with difficulty clearing mucous. Which of the following additional assessment findings is most consistent with the patient's presentation? Answer Options * Bradycardia Stridor Cyanosis Bradypnea
Principle:
A systolic blood pressure less than 90 is typically reported immediately unless it's consistent with the client's baseline ; Page# 459
Perform postural drainage before eating meals
The nurse is teaching a client's family member about postural drainage. Which of the following statements made by the caregiver indicates that they will perform this procedure safety? Answer Options * Maintain the head of bed to at least 90 degrees Notify the physician if the mucus becomes thick Perform postural drainage before eating meals Provide narcotic analgesics before procedure
Tissues are not receiving enough oxygen
The nurse is using pulse oximetry on the client with Chronic Obstructive Pulmonary Disease (COPD). How does the nurse interpret the information obtained by the pulse oximetry (SpO2) reading of 86%? Answer Options * Tissues are not receiving enough oxygen Oxygen saturation of hemoglobin is within normal limits Hypersaturation of the red blood cells is occurring A complete blood count is needed to detect possible anemia
Surfactant
The nurse knows that which of the following substances helps to prevent atelectasis? Answer Options * Surfactant Magnesium Aldosterone Protein
Check the client's blood pressure prior to administering
The nurse receives an order to give a bolus of normal saline 0.9% to a client with severe dehydration. Which action by the nurse is appropriate? Answer Options * Start the intravenous with a 24 gauge angiocathether Check the client's blood pressure prior to administering Assess the sodium level and oxygen saturation level Elevate the head of the bed to a 90 degree angle
A client is scheduled for surgery and is being questioned by the nurse. Which of the following statements by the client is of most concern for the perioperative nurse?
'I took my ginseng to make sure I had enough energy for the surgery.'
A client is scheduled for a surgical procedure that requires local anesthesia. The nurse determines that the instructions were not understood when the client makes which of the following statements?
'I will be intubated during the procedure.'
A client is diagnosed with lung cancer and is scheduled for a gallium lung scan after chemotherapy. The nurse educates the client on what to expect during the scan. Which statement made by the client reflects understanding? Answer Options * 'I should flush the toilet twice for the first 24 hours following the procedure.' 'The injection is radioactive so I must avoid my family while waiting to be scanned.' 'I can't have anything to eat or drink 8 hours before the procedure.' 'I will have to remember to drink a lot of water after the scan is completed.'
'I will have to remember to drink a lot of water after the scan is completed.'
The lab calls to report the peak and trough levels on the client receiving intravenous (IV) vancomycin. The client wants to know why these levels were drawn. Which of the following is the nurse's best response? Answer Options * 'To prevent side effects like flushing and redness that's caused by this medication.' 'To help determine the dosing of the drug and how often you should receive it.' 'To provide information on how fast a rate we can administer the drug.' 'To help with the selection of which type of drug will help you get well.'
'To help determine the dosing of the drug and how often you should receive it.'
Shallow respirations Dyspnea PaCO2 58 mm Hg
A client is diagnosed with acute respiratory distress syndrome (ARDS). Which of the following clinical data support that the client is in acute respiratory failure? Select all that apply. Answer Options * PaO2 85 mm Hg Shallow respirations Excessive mucous production Dyspnea PaCO2 58 mm Hg
Notify the primary care provider.
A client who is one day postoperative after a mastectomy becomes increasingly restless and agitated. The nurse observes that the hemovac is almost filled with bloody drainage. Vital signs are as follows; temperature, 100 F; pulse, 98 beats/min; respiration's, 24/breaths/min; and blood pressure, 120/80 mm Hg. Which intervention would the nurse implement first? Answer Options * Administer the prescribed antipyretic. Empty and record the hemovac. Have the UAP take vital signs hourly. Notify the primary care provider.
Stop the assessment and call the rapid response team stat
A 26 year old male presents to the emergency department with difficulty speaking as well as facial and periorbital swelling. The nurse hears audible stridor during the assessment. Which action by the nurse is appropriate? Answer Options * Finish the assessment and report the findings to the provider Stop the assessment and call the rapid response team stat Encourage the client to perform coughing and deep breathing Encourage the client to take deep breaths and hold for 3 seconds
Page an interpreter from the hospital's interpreter services.
A Spanish-speaking client arrives at the triage desk in the emergency department and informs the nurse that she can't speak English. Which is the best action for the nurse to take? Answer Options * Have one of the client's family members translate for the client. Have the Spanish-speaking triage receptionist interpret. Page an interpreter from the hospital's interpreter services. Obtain a Spanish-English dictionary and attempt to triage the client.
Encourage the client to cough up secretions.
A client begins to cough during a suctioning procedure. Which of the following is the nurse's next action? Answer Options * Encourage the client not to cough. Obtain an order for an arterial blood gas. Assess the client for central cyanosis. Encourage the client to cough up secretions.
Place the client in a modified Trendelenburg position
A client being treated with antihypertensives has a sudden drop in blood pressure. Which action should the nurse take next? Answer Options * Call the primary care provider immediately Encourage the client to ambulate with your assistance Ask the client when was the last time they voided Place the client in a modified Trendelenburg position
Notify the attending surgeon
A client had abdominal surgery 24 hours ago. The licensed practical nurse (LPN) notes that the abdominal dressing has serosanguinous drainage on it. Which action by the LPN is appropriate? Answer Options * Instruct the client to stay in bed Lower the head of the bed to 30 degrees Change the dressing immediately Notify the attending surgeon
Avoid quick position changes until you are comfortable with the drug.'
A client has been prescribed furosemide (Lasix). Which teaching instruction by the nurse is a priority for this client
Notifies the surgeon of the findings
A client has returned from surgery with a foley catheter. The nurse finds the patient in bed with signs of lethargy. The vital signs are 96/76, 99.5, 114, 24 and the total urinary output over the last two hours is 30 ml. Based on this information, the nurse Answer Options * Elevates the head of the bed Notifies the surgeon of the findings Checks the white blood cell count Irrigates the patient's foley catheter
This week I have had several headaches so I took a few aspirin.'
A client is about to have an elective surgical procedure. Which statement by the client should be immediately reported to the surgeon? Answer Options * 'I had a couple of beers a few days ago at a birthday party.' 'I was told that I was allergic to penicillin when I was a child.' 'Before coming in, I had a few cigarettes in the car ride over.' This week I have had several headaches so I took a few aspirin.'
Administer the infusion of normal saline
A client is admitted to the surgical unit after having abdominal surgery. The nurse obtains the following vital signs, blood pressure 100/82, pulse 116, respirations 24 and temperature of 100.4 F. The surgeon states that the client is hypovolemic and orders a bolus of 0.9% NS. Which action by the nurse is appropriate? Answer Options * Elevate the head of the bed Question the order with the surgeon Administer the infusion of normal saline Obtain an order for a blood culture
'I can use it to help determine how well I am breathing.'
A client is diagnosed with asthma. The nurse is explaining the use of a peak flow meter. Which of the following statements made by the client reflects understanding of the purpose of using a peak flow meter in asthma management? Answer Options * 'It will help me know when I'm wheezing in case I can't hear it.' 'It will show me how many puffs of my steroid inhaler I need to take.' 'I can use it to help determine how well I am breathing.' 'It measures the amount of air flowing into my lungs when I breathe.'
'I will have to remember to drink a lot of water after the scan is completed.'
A client is diagnosed with lung cancer and is scheduled for a gallium lung scan after chemotherapy. The nurse educates the client on what to expect during the scan. Which statement made by the client reflects understanding? Answer Options * 'I should flush the toilet twice for the first 24 hours following the procedure.' 'The injection is radioactive so I must avoid my family while waiting to be scanned.' 'I can't have anything to eat or drink 8 hours before the procedure.' 'I will have to remember to drink a lot of water after the scan is completed.'
Determine if the client needs suctioning
A client is receiving mechanical ventilation. The nurse notices the alarm beeping high pressure. Which action should the nurse take next? Answer Options * Assess the ventilator setup and settings Determine if the client needs suctioning Notify the respiratory therapist promptly Turn off the ventilator and reposition the client
Side-lying knee chest
A client is scheduled for a lumbar puncture. Which position will the nurse assist the client to facilitate this procedure? Answer Options * Low Fowler's Prone Side-lying knee chest Left lateral Sim's
Any sedative type of medication has been recently given
A client is scheduled for surgery. Legally, the client may not sign the operative consent if: Answer Options * Any history of allergies to iodine are reported Any sedative type of medication has been recently given A discussion of alternatives with two physicians has not occurred A complete history and physical has not been performed and recorded
'I can eat a light breakfast before the procedure'
A client is scheduled to have a leg wound surgically debrided. The nurse reviews the plan of care with the client. Which statement by the client suggests that the teaching was understood? Answer Options * 'I will call the surgeon if the wound bed is red' 'I can eat a light breakfast before the procedure' 'I may sweat at night during the healing process' 'I will press lightly over the wound when I cough'
Risk for upper airway obstruction
A client presents with an altered level of consciousness. Which of the following conditions is the client most at risk for? Answer Options * Risk for upper airway obstruction Risk for bowel incontinence Risk for cerebral vascular accident Risk for abdominal distention
Check the carotid artery for a pulse
A client returns to the unit after having a pulmonary angiography performed. Which of the following interventions is a priority? Answer Options * Measure the client's blood pressure Assess the client's gag reflex Check the carotid artery for a pulse Place the client in a prone position
Hematoma to puncture to site
A client was sent for a pulmonary angiography after presenting with signs of a pulmonary embolism. When the client returns to the unit, the nurse should immediately report which of the following findings to the health care provider. Answer Options * A systolic blood pressure of 130 Hematoma to puncture to site Respirations of 24 Increased sputum production
Confirm that the client has a positive gag reflex
A client who had a bronchoscopy performed returns to the unit and is requesting breakfast. Which of the following actions should the nurse take first? Answer Options * Assess when the client had their last bowel movement Give the client a clear liquid diet to start Determine whether the client can tolerate ice chips Confirm that the client has a positive gag reflex
Administer oxygen via a nasal cannula
A client who had a bronchoscopy returns to the unit and complains of difficulty breathing. The nurse auscultates stridor and notes that the client is using accessory muscles. Which of the following interventions has the highest priority? Answer Options * Ask the client how long they had dyspnea Administer oxygen via a nasal cannula Instruct the client to take long deep breaths Call respiratory to obtain an arterial blood gas
Hypoxia and hypercapnia
A client who had a bronchoscopy with lung biopsy performed just returned to the unit. The nurse notes the client's respiratory rate is 10. The nurse knows that this finding could lead to which of the following complications? Answer Options * Hypoxia and hypercapnia Orthopnea and dyspnea Metabolic acidosis Respiratory alkalosis
Check the client's blood pressure
A client who had an epidural for anesthesia complains of feeling dizzy. Which action should the nurse take next? Answer Options * Encourage the client to drink more Check the client's blood pressure Assess the epidural injection site Elevate the head of the bed
Document the findings in the electronic medical record.
A client who has a history of running marathons presents to the clinic for an annual physical exam. Upon gathering the vital signs, the nurse notes the client's resting blood pressure is 98/58, and heart rate of 48. Which action by the nurse is appropriate for this finding? Answer Options * Assess the most recent results of the arterial blood gas. Ask the nurse supervisior to repeat the blood pressure. Document the findings in the electronic medical record. Get immmediate help and obtain the on-site crash cart.
Put on a surgical mask and gloves before entering the client's room.
A client who is on droplet precautions is on a telemetry unit. The technician reports to the nurse that the telemetry device shows ventricular fibrillation. Which action would the nurse take next? Answer Options * Have the technician call a rapid response immediately. Put on a surgical mask and gloves before entering the client's room. Obtain a defibrillator and put on an N95 mask and gloves. Place an N95 mask on the client prior to assessing the heart rate.
Ask the client when ginseng was last taken
A client who is scheduled for surgery admits to taking ginseng for energy. Which action would the nurse take next? Answer Options * Ask the client when ginseng was last taken Have the client sit down and obtain the vital signs Notify the surgeon about this finding immediately Assess the client's hemoglobin and hematocrit level
Awake the client and obtain vital signs.
A nurse enters a client's room when the pulse oximeter alarms and reads 82%. The client appears to be sleeping. Which action should the nurse take first? Answer Options * Gently apply oxygen without waking the client. Record the reading and monitor for further decrease. Reposition the pulse oximeter and notify the provider. Awake the client and obtain vital signs.
Decreased heart rate and decreased blood pressure
A nurse is admitting a client with a diagnosis of hypothermia to the hospital. Which of the following signs does the nurse anticipate that this client will exhibit? Answer Options * Increased heart rate and increased blood pressure Increased heart rate and decreased blood pressure Decreased heart rate and increased blood pressure Decreased heart rate and decreased blood pressure
Blood pressure of 110/82; pulse 110; urinary output 150 mL in 8 hours.
A nurse is caring for a client who has a fever and is diaphoretic. Which finding should the nurse report immediately? Answer Options * Blood pressure of 118/59; pulse 112; urinary output 400 mL in 8 hours. Blood pressure of 121/84; pulse 108; urinary output 650 mL in 8 hours. Blood pressure of 110/82; pulse 110; urinary output 150 mL in 8 hours. Blood pressure of 144/80; pulse 99; urinary output 240 mL in 8 hours.
Administer oxygen at 2L/min by nasal canula
A nurse is caring for a client with asthma. The nurse notes that the client is wheezing and the oxygen saturation is 90% on room air. Which of the following actions should the nurse take first? Answer Options * Monitor the client's peakflow meter every hour Call the respiratory team for a breathing treatment Administer oxygen at 2L/min by nasal canula Monitor the client's pulse oxymetry and vitals
Administer oxygen via nasal canula
A nurse is caring for a client with right lower lobe pneumonia. The nurse notices that the client becomes disoriented, complains of dyspnea, and is agitated. The client's heart rate is 116. Which of the following actions should the nurse take first ? Answer Options * Administer oxygen via nasal canula Call the rapid response team immediately Prepare to obtain arterial blood gases Position the client onto the right side
Principle:
A trained medical interpreter is used when English is not understood ; Page# 422
Changes in respiratory rhythym
The client presents to the emergency department (ED) with a suspected brain stem injury. The nurse notes which of the following clinical signs as consistent with this type of head injury? Answer Options * Rapid speech Pupils reactive to light Changes in respiratory rhythym Change in sense of smell
Unequal lung expansion
The client presents to the emergency department (ED) with chest trauma. The nurse should assess for which of the following clinical signs of pneumothorax? Answer Options * Pink, frothy sputum Barrel-shaped chest Unequal lung expansion Clubbing to the nail beds
Productive cough Inspiratory and expiratory wheezing Use of accessory muscles
The client presents to the emergency department with a suspected asthma attack. Which of the following assessment findings are consistent with this disorder? Select all that apply.
The lab calls the unit with the client's arterial blood gas levels: pH 7.30, paO2 47 mmHg, paCO2 55 mmHg, HCO3 29mEq/L. Which of the following is the nurse's priority intervention? Answer Options * Repeat the arterial blood gas levels. Prepare for intubation and mechanical ventilation. Administer a bronchodilator. Obtain pulse oximetry readings
Prepare for intubation and mechanical ventilation. Principle: Clinical signs of respiratory failure with or without acidosis indicates a need for mechanical ventilation. ; Page# 522
Assess for cyanosis around the mouth, lips, cheekbones and earlobes (grayish cast) in a darker complexion ; Page# 490
Principle:
Confusion may be a sign of early sepsis, fever or hypoxemia ; Page# 551
Principle:
Cyanosis alone is NOT a reliable sign of hypoxia! ; Page# 492
Principle:
Heart rate of 116
Acute pain affects the sympathetic nervous system. Which of the following clinical manifestations is the nurse likely to assess when caring for a client with acute pain. Answer Options * Decrease in blood pressure Heart rate of 116 Pupil constriction Deep tendon reflex +4
Principle:
Acute respiratory failure is manifested by a decrease in PaO2 (less than 50 mm Hg) and an increase in PaCO2 (greater than 50 mm Hg) with respiratory acidosis ; Page# 609
Hypoventilation that is prolonged could result in atelectasis ; Page# 496
Principle:
Restlessness or a change in mental status could indicate hypoxia ; Page# 462
Principle:
Principle:
Adequate liver and renal function are needed to ensure proper metabolism and elimination of substances ; Page# 428
Instruct the client to remain in bed and notify the health care provider.
After abdominal surgery a client suddenly reports heaviness to the right leg. The nurse notes that the right calf looks bigger than the left calf. What would the nurse do first? Answer Options * Place client in semi-Fowler's position with knee-gatch and encourage fluid intake. Instruct the client to remain in bed and notify the health care provider. Rub the client's legs to stimulate circulation and cover the leg with a blanket. Assess pedal pulses in both extremities and obtain an order for a diuretic.
Dantrolene
After surgery with general anesthesia, a client develops tachycardia, muscle rigidity and an elevated temperature. Which of the following medications should the nurse anticipate administering? Answer Options * Acetaminophen Vitamin K Dantrolene Narcan
Principle:
All surgical procedures have the risk of hemorrhage! ; Page# 417
Venturi mask
Principle: The venturi mask is the most precise way to deliver a set concentration of oxygen ; Page# 512 The venturi mask is the most precise way to deliver a set concentration of oxygen ; Page#
The nurse is caring for a client with respiratory acidosis who has a history of emphysema. The nurse understands that respiratory acidosis most likely occurred due to an impairment of which of the following structures?
Alveoli
Principle:
An NPO status must be maintained until the gag reflex returns! ; Page# 492
Principle:
An altered level of consciousness increases ones risk for upper airway obstruction ; Page# 522
Rapid infusion of normal saline in the elderly increases risk of pulmonary edema.
An elderly client had 2 liters of normal saline rapidly infused to reverse a hypotensive episode; however, now the client has developed crackles upon reassessment. The nurse understands the reason for this findings is due to which of the following? Answer Options * The client's age reduces the ability to ventilate adequately causing fluid build up. Infusing normal saline rapidly could result in temporary renal impairment. Rapid infusion of normal saline in the elderly increases risk of pulmonary edema. The client probably has a longstanding history of cigarette smoking.
You should not wear artificial nails at all and will have to take them off.
An infection control nurse is giving an inservice on measures to help decrease the spread of infection. A nurse asks how short the artificial nails have to be. How should the infection control nurse respond? Answer Options * You should keep the artificial nails no longer that the tip of your finger. You should keep the artificial nails no longer than a 1/4 inch long. You should not wear artificial nails at all and will have to take them off. You should not wear artificial nails on any of the patient care specialty units.
Principle:
An order for oxygen is NOT required during an emergency! ; Page# 511
Encourages the client to cough.
An unlicensed assistive person is in the room with a client who had intracranial surgery and appears to be uncomfortable. Which action by the UAP requires intervention? Answer Options * Keeps the head-of-bed 30 degrees. Encourages the client to cough. Asks the client if there's any pain. Puts a blanket over the client's legs.
Principle:
Anaphylaxis is a life threatening sudden allergic reaction ; Page# 450
AST and ALT and Creatinine
Prior to administering medications to patients on a medical unit, the nurse assesses which of the following labs to help reduce the patient's risk for drug toxicity? Answer Options * Serum electrolytes and albumin level Hemoglobin and hematocrit AST and ALT and Creatinine Blood urea nitrogen (BUN) and complete blood count
Principle
Provide around the clock administration of analgesics for chronic and postoperative pain, never wait for chronic pain to reoccur ; Page# 459
Principle:
Provide patient controlled analgesia to help reduce complicatons related to pain ; Page#
Principle:
Provide patient controlled analgesia to help reduce complicatons related to pain ; Page# 459
A pedal pulse of + 1 bilaterally
The client returns from surgery for an abdominal aneurysm repair. The client has a history of peripheral vascular disease. Which situation would alert the nurse to a potential complication? Answer Options * An order for anti-embolism stockings Capillary refill is less than 3 seconds A pedal pulse of + 1 bilaterally Skin to legs is dark and brawny
The hemoglobin level is 7.8 g/dL postoperatively.
The nurse is caring for a client who is receiving a continuous bladder irrigation after a transurethral resection of the prostate gland (TURP). Which finding should be reported to the primary health care provider? Answer Options * The client reports a continuous feeling of needing to void. Urinary drainage is pink 24 hours after surgery. The hemoglobin level is 7.8 g/dL postoperatively. Sterile saline is being used for bladder irrigation.
Respiratory acidosis
The client who has atelectasis is experiencing dyspnea. The client has shallow rapid breaths but is struggling to get air out. Which acid-base disorder would the nurse expect when reviewing arterial blood gas results?
Serum electrolyte values
Which lab value will be of most concern for an elderly client who is scheduled for surgery and has taken the bowel preparation GoLytely? Answer Options * Serum creatinine values Hemoglobin and hematocrit Serum electrolyte values Total white blood cell count
The client's respiratory rate is 16 breaths/minute.
The healthcare provider prescribes naloxone (Narcan) for a client in the emergency room. Which assessment data would indicate that the naloxone has been effective? Answer Options * The client states that the chest pain is better. The client's respiratory rate is 16 breaths/minute. The client's seizure activity has stopped temporarily. The client's pupils are constricted bilaterally.
Administer oxygen 100% via a nonrebreather mask
The nurse enters the client's room and observes a respiratory rate of 28, progressive dyspnea with decreased movement of the chest wall, and nasal flaring. Which action should the nurse take first? Answer Options * Lower the head and prepare for mechanical ventilation Call the physician to report the findings immediately Administer oxygen 100% via a nonrebreather mask Obtain a order for a chest x-ray and arterial blood gas
Principle:
Any condition that prevents CO2 elimination increases the patient's risk for acidosis ; Page# 488
Principle:
Any condition that restricts chest expansion (obesity, pain, abdominal distention) could result in hypoventilation ; Page# 489
S4
Aortic stenosis, hypertrophic subaortic stenosis
Ventilate client manually with a resuscitation bag
The nurse enters the room of a client on mechanical ventilator and finds the T-piece on the client's chest. The nurse notices a heart rate of 158 sustained and observes labored breathing. Which action should the nurse take first? Answer Options * Obtain an oxygen saturation level immediately Instruct the client to take slow deep breaths Assess the client's lungs sounds and respirations Ventilate client manually with a resuscitation bag
Principle:
Artificial nails for health care providers are banned by many institutions since they are typically associated with higher bacterial counts; keep natural nails less than 1/4 inch long ; Page# 442
Principle:
Aspirating vomitus may trigger an asthma-like response ; Page# 450
Principle:
Aspirin should NOT be taken 7-10 days prior to surgery ; Page# 426
Principle:
Assess for cyanosis around the mouth, lips, cheekbones and earlobes (grayish cast) in a darker complexion ; Page# 490
Principle:
Assess the side and back of a patient's dressing for bleeding following surgery ; Page# 1526
Bluish cast to mucous membranes.
The nurse interprets which of the following clinical findings as a late sign of hypoxia? Select all that apply.
Question Description The client with lung cancer has developed increasing dyspnea, cough, and sputum production. The client denies any pain but the nurse notices facial grimacing and bradypnea. The nurse suspects which of the following complications may have developed in this client? Select all that apply. Answer Options * Acute respiratory distress syndrome Atelectasis Pulmonary infection Asthma Emphysema
Atelectasis Pulmonary infection
Principle
Avoid suctioning longer than 15 seconds since it could lead to dysrhythmias and cardiac arrest ; Page# 523
Principle:
Bleeding is always a risk of angiograpy and procedures ending in oscopy (ex. bronchoscopy)! ; Page# 500
Principle:
Bowel preps increase the risk for fluid and electrolyte deficits ; Page# 429
Principle:
CO2 diffuses (high to low concentration) out of the cell into the bloodstream while O2 diffuses out of the bloodstream and into the cells. ; Page# 488
Principle:
Change the patients position slowly to prevent orthostatic hypotension ; Page# 458
Principle:
Classic signs of deep vein thrombosis include edema to the extremity, warmth, tenderness or fullness in the leg ; Page# 868
Principle:
Clinical manifestations of arterial insufficiency include pain, diminished pulse, pallor, dependent rubor, cool temparture, absence of hair, thickened nails ; Page# 851
Principle
Clinical manifestations of pulmonary embolism consist of chest pain, cough, dyspnea, hypoxemia, tachycardia, tachypnea, petechiae and restlessness ; Page# 835
Principle
Clinical signs of respiratory failure with or without acidosis indicates a need for mechanical ventilation. ; Page# 522
The nurse is caring for a client with a long term history of chronic obstructive pulmonary disease (COPD). Which of the following physical assessment findings would be consistent with this disorder? Answer Options * Peripheral edema Concave chest Flat neck veins Clubbing of nail beds
Clubbing of nail beds
Principle:
Clubbing of the nails could be indicative of long-standing hypoxia ; Page# 492
A client is diagnosed with asthma. The nurse is explaining the use of a peak flow meter. Which of the following statements made by the client reflects understanding of the purpose of using a peak flow meter in asthma management? Answer Options * 'It will help me know when I'm wheezing in case I can't hear it.' 'It will show me how many puffs of my steroid inhaler I need to take.' 'I can use it to help determine how well I am breathing.' 'It measures the amount of air flowing into my lungs when I breathe.'
Correct Answer: 'I can use it to help determine how well I am breathing.'
The nurse is caring for the client in cardiogenic shock. The nurse knows that one of the earliest signs of cardiogenic shock is which of the following? Answer Options * Decreased urinary output Cyanosis Confusion or restlessness Bounding pulse
Confusion or restlessness
Principle
Crackles is a sign of fluid accumulation typically auscultated in the lower basis of the lungs ; Page#
Principle:
Cultures should be performed prior to starting an antibiotic ; Page# 501
Principle:
Cyanosis alone is NOT a reliable sign of hypoxia! ; Page# 492
Principle:
Cyanosis is a LATE sign of hypoxia ; Page# 493
Principle:
Cyanosis occurs when there is a minimum loss of 5g/dL of unoxygenated hemoglobin in the blood ; Page# 492
Principle
Contrast medium is nephrotoxic and is contraindicated if the patient has allergies to iodine, shellfish, or seafood, is pregnant or has an elevated creatinine ; Page# 57
Principle
Corticosteroids and alcohol may increase the risk of infection ; Page#
Principle:
Corticosteroids and alcohol may increase the risk of infection ; Page# 426
Principle
Corticosteroids inhibit the inflammatory response, suppress adrenal gland activity, increase the risk of hyperglycemia and hypernatremia, and hypokalemia, and could mask infection ; Page# 1532
Principle:
Coughing increases intracranial pressure and should not be encouraged following intracranial surgery or in the setting of a head injury! ; Page# 458
Principle
Coughing, wheezing,increased mucous production and dyspnea are typically present during an asthmatic attack ; Page#
Principle:
Coughing, wheezing,increased mucous production and dyspnea are typically present during an asthmatic attack ; Page#
Principle
Damage to the alveolar-capillary membrane or exudate in the alveoli impairs gas exchange ; Page# 484
Principle:
Dantrolene is the antidote for malignant hyperthermia ; Page# 452
Principle:
Dark nail polish (black or blue), acrylic nails or cold extremities affect the accuracy of the pulse oximeter ; Page# 457
Principle:
Deep breathing helps to eliminate residual anesthetic agents ; Page# 457
Principle
Deoxygenated blood leaves the right side of the heart through the pulmonary artery and carbon dioxide diffuses into the alveoli while oxygen diffuses into the pulmonary capillary and is brought back to the left side of the heart via the pulmonary veins ; Page# 673
Nothing since there was no contamination of the field.
During a sterile procedure, the surgeon touches part of an instrument with his or her elbow. Which action by the circulating nurse is most appropriate? Answer Options * Offer the surgeon a new pair of gloves before continuing. Ask the surgeon to keep the elbows above the sterile field. Have the surgeon pass off the instrument to be resterilized. Nothing since there was no contamination of the field.
Weight loss and chronic fatigue
During shift report two nurses are discussing a recently admitted client who is significantly under weight and frail. In suspecting a diagnosis of a malignant form of cancer, which of the following assessment findings should the nurses know to be cardinal signs of malignant cancer? Answer Options * Tachycardia and malignant hyperthermia Weight loss and chronic fatigue Low hemoglobin and hematocrit Low hemoglobin and fatigue
Principle
Early ambulation is key to preventing postoperative complications ; Page#
Principle
Early ambulation is key to preventing postoperative complications ; Page# 467
Principle
Egophony changes the E to an A sound with consolidation ; Page# 497
Principle:
Elevate the head of the bed to promote lung excursion if the patient is hemodynamically stable ; Page# 615
Your Answer: Abrupt onset of confusion and restlessness
The nurse is admitting a client who just returned from having abdominal surgery. The baseline hemoglobin is 13 g/dL and the hematocrit is 39%. Which of the following observations should be immediately reported to the healthcare provider? Answer Options * Abrupt onset of confusion and restlessness Oxygenation saturation drops from 97 to 95 Hemoglobin of 15 g/dL and hematocrit of 45% Blood pressure of 146/86 when sitting
Principle:
Epidural anesthesia could result in life threatening hypotension and respiratory depression ; Page# 445
Epinephrine
The nurse is assessing a client who is experiencing anaphylaxis from a bee sting. Which of the following medications should the nurse prepare to administer this client? Answer Options * Dopamine Ephedrine Epinephrine Narcan
Yes, but you should report any signs of redness or swelling'
Following a surgical procedure, a client is instructed to resume all prior medications. The client wants to know if this includes the prednisone. Which response made by the nurse is appropriate? Answer Options * 'Yes, but you should report any signs of redness or swelling' 'Yes, as long as you take it with 8 ounces of water you should be OK' 'No, this medication increases inflammation so don't take it' 'No, you should not resume any medications that are over the counter'
The nurse is providing preoperative teaching to the client scheduled for abdominal surgery. Which key points would the nurse include to help the client prevent complications from surgery? Select all that apply.
Getting the client out of bed to ambulate with assistance. Having around-the-clock pain medication made available. Splinting the incision when coughing and deep breathing.
One day following surgery to the right knee, a client who has diabetes suddenly complains of chest pain and becomes pale and diaphoretic. Vital signs are, blood pressure 100/70 mm Hg, pulse 120 beats/min, and respirations 36 breaths/min. Which action is most important for the nurse to take? Answer Options * Have the client breathe into a paper bag. Administer a prescribed PRN analgesic. Have the client drink a glass of fruit juice. Give oxygen at 2 L via nasal cannula.
Give oxygen at 2 L via nasal cannula.
Principle:
Gowns are sterile from the chest to the level of the table and 2†above the elbow ; Page# 439
The nurse is assessing cyanosis in a client with a dark complexion. Which of the following physical assessments for cyanosis will be most reliable for this client? Select all that apply? Answer Options * Gray color of the lips Gray color of the fingertips Gray color of skin around the mouth Gray color of sclera Gray color of the earlobes
Gray color of the lips Gray color of skin around the mouth Gray color of the earlobes
Principle
Hand hygiene is the single most effective way to prevent the spread of infection ; Page# 553
Chest pain, dyspnea, restlessness, paresthesia
The nurse is caring for a client on a mechanical ventilator and suspects that the client has received too high of a concentration of oxygen. Which of the following signs and symptoms are associated with oxygen toxicity ? Answer Options * Increased heart rate, agitation, and mental alertness Chest pain, dyspnea, restlessness, paresthesia Diaphoresis, increased blood pressure, and confusion Bradycardia, disorientation, agitation, and restlessness
Principle
Herbal medicines that interfere with coagulation should not be used 2 weeks prior to surgery ; Page# 534
Principle:
Herbal medicines that interfere with coagulation should not be used 2 weeks prior to surgery ; Page# 534
Principle:
Hydrogen ions are exchanged for potassium ions during alkalosis or acidosis (i.e. metabolic acidosis results in hyperkalemia as H ions are shifted into the cell to raise the pH and potassium leaves the cell and enters the bloodstream) ; Page# 1543
Principle
Hyperglycemia can increase the risk for surgical site infection ; Page# 428
Principle
Hyperglycemia, metabolic acidosis, dehydration and electrolyte imbalance are clinical features that present with diabetic ketoacidosis ; Page# 1483
Principle
Hyperoxygenate the patient for thirty seconds prior to suctioning ; Page# 523
Principle:
Hypothermia decreases cellular oxygen requirements ; Page# 450
Principle:
Hypoventilation leads to hypoxia and hypercapnia ; Page# 636
Principle
Hypoxia could lead to cardiac dysrhythmias and death! ; Page# 535
Oozing of blood or a hematoma at the injection site
The nurse is caring for a client who had an angiography. The nurse should monitor for which of the following signs of a complication? Answer Options * Sharp increased pain to the bilateral lower extremities Nausea, vomiting, diarrhea, upon returning to the unit Oozing of blood or a hematoma at the injection site An elevated temperature with increased urinary frequency
Place the client in a low-Fowler's position
The nurse is caring for a client who had major abdominal surgery 2 days ago. Upon entering the room the client states that something popped. The nurse observes a wound dehiscence. Which action should the nurse take next? Answer Options * Cover the abdomen with a dry sterile gauze Gently push the contents under the skin Encourage the client to breath deeply and cough Place the client in a low-Fowler's position
Metabolic acidosis
The nurse is caring for a client who has type I diabetes and a blood glucose reading of 671 mg/dl. Which of the following assessment findings is consistent with diabetic ketoacidosis? Answer Options * Respiratory acidosis Metabolic acidosis Fluid volume overload Difficulty urinating
What priority intervention is needed prior to the client undergoing a cardiac catheterization? Select all that apply.
Identify allergies to iodine, shellfish, or dye. Explain flushing sensation may be experienced.
Principle:
Inflate the cuff on a trach to help prevent aspiration while using mechanical ventilation ; Page# 515
principle
Injury to the brainstem impairs respiratory function ; Page# 486
Principle
Instruct on coughing and deep breathing and the incentive spirometer to help remove secretions and promote lung expansion ; Page#
Principle:
Intravascular fluid contributes to one's blood pressure or perfusion pressure ; Page# 459
Principle:
Large amounts of bloody drainage in a wound drain could suggest hemorrhage and must be reported immediately! ; Page# 468
Principle
Less invasive measures should be used to assist the client with voiding prior to catheterization ; Page# 458
Principle:
Lung auscultation and pulse oximetry are key assessments for determining the adequacy of ventilation ; Page# 502
Principle
Lung ventilation and perfusion mis-matches could result in hypoxia ; Page# 486
Principle:
Lung ventilation and perfusion mis-matches could result in hypoxia ; Page# 486
Principle:
Magnesium sulfate is a calcium antagonist and can be given to relax smooth muscle ; Page# 666
Principle:
Medications tend to be more potent and the effects last longer in the elderly ; Page# 437
Principle:
Milking the chest tube helps to prevent obstructions but could increase negative pressure and damage pleural tissue ; Page# 541
Principle:
Monitor vital signs q 15 minutes for the first hour and then q 30 minutes for the next two hours following surgery ; Page# 461
Principle:
NEVER leave a client alone when administering conscious sedation ; Page# 445
Principle:
Narcotic antagonists combat opioid toxicity ; Page# 442
Principle:
Not all clients need to be NPO prior to surgery ; Page#
Principle
Numerous factors may cause an inaccurate pulse oximetry result! ; Page# 502
Principle:
Nurses must don the appropriate personal protective equipment when there's a risk for coming into contact with blood or body fluids ; Page# 468
To reduce post op surgical complications
Patient controlled analgesia (PCA) has been ordered for a client who had surgery 6 hours ago. The nurse knows that which of the following best explains the main reason for providing PCA? Answer Options * To reduce some of the nursing activities To strengthen the autonomy level of the client To increase the effectiveness of the nursing staff To reduce post op surgical complications
Principle:
Patients are awake with regional or local anesthesia ; Page# 445
Principle:
Peak flow meters can be used to determine the adequacy of interventions to improve expiratory function ; Page# 511
The older adult client with an indwelling catheter is transferred from a nursing home. The client complains of urinary frequency and burning. Which of the following interventions that the health care provider orders should the nurse perform first? Answer Options * Start an intravenous line. Start oral ciprofloxacin. Transfer from bed to chair. Obtain urine cultures.
Obtain urine cultures. Principle: Cultures should be performed prior to starting an antibiotic ; Page# 501
Principle
Oxygen and carbon dioxide diffuse through the alveolar-capillary membrane ; Page# 485
Principle
Oxygen delivery to the cells is diminshed in the setting of anemia ; Page#
Principle:
Oxygen toxicity can kill cells and is evident by restlessness, dyspnea and paresthesias. ; Page# 512
The nurse suspects hypoxia in a client who presents to the emergency department (ED) with dyspnea. The nurse recognizes which of the following as the most reliable indicator of hypoxia? Answer Options * Cold clammy skin Respiratory rate 26 breaths/ minute Cyanosis PaO2 of 75 mm Hg
PaO2 of 75 mm Hg
Principle:
Page# Correlate lab values with the patient's signs and symptoms ; Page#
Principle:
Pain stimulates the sympathetic nervous system and could result in an increase in blood pressure, heart rate and respirations ; Page# 459
Principle:
Place a client flat on their back with legs elevated at a 20-degree angle (knees straight) for the shock position ; Page# 459
Principle:
Place the patient in a low Fowler's position following a wound dehiscence to reduce tension on the abdominal wound ; Page# 468
Principle:
Place the patient in a side-lying knee chest position for lumbar punctures ; Page# 452
Principle
Position the patient onto the operative side following a pneumonectomy and onto the unaffected side following a lobe resection ; Page# 537
Principle:
Postural drainage is performed before meals!! ; Page# 517
Principle:
Pulse oximetry is used to detect hypoxemia ; Page# 457
Principle:
Pulse oximetry is used to detect hypoxemia ; Page# 502
Principle
Radiation safety measures are not necessary for V/Q or gallium scans ; Page# 500
Principle:
Radiation safety measures are not necessary for V/Q or gallium scans ; Page# 500
Principle:
Raise side rails following the administration of pre-anesthetic medications ; Page# 426
Principle:
Rapid IV solution administration in the elderly increases the risk of pulmonary edema ; Page# 437
principle
Reduce the risk for infection with elderly; drink plenty of fluids unless contraindicated, use lotion, assessing for signs of skin breakdown, change incontinence pads frequently, void after intercourse, pneumococcal and influenza vaccine, cough and deep breathing exercies, sit up while eating ; Page# 460
Principle:
Report urinary output less than 30 ml/hr ; Page# 458
The client who has atelectasis is experiencing dyspnea. The client has shallow rapid breaths but is struggling to get air out. Which acid-base disorder would the nurse expect when reviewing arterial blood gas results?
Respiratory acidosis
The nurse assesses the need for oxygen therapy in the client presenting to the emergency department (ED). Which of the following physical findings would indicate the need for oxygen therapy? Select all that apply. Answer Options * Respiratory rate 28 Restlessness Dyspnea Blood pressure 130/80 Oxygen saturation of 95%
Respiratory rate 28 Restlessness Dyspnea
Principle
Restlessness or a change in mental status could indicate hypoxia ; Page# 462
Principle:
Restlessness or a change in mental status could indicate hypoxia ; Page# 462
Principle
Restlessness or a change in mental status could indicate hypoxia ; Page# 826
S4 heard just before
S1 is generated during atrial contraction as blood forcefully enters a noncompliant ventricle.
S4—Fourth Heart Sound
S4 ("LUB") occurs late in diastole.
Principle
Signs of hypoxia include restlessness, confusion, pallor, tachycardia and tachypnea ; Page# 512
Principle:
Signs of hypoxia include restlessness, confusion, pallor, tachycardia and tachypnea ; Page# 512
Principle:
Since mechanical ventilators push air into the alveoli, a high pressure alarm signals obstruction while a low pressure alarm signals air escape ; Page# 525
Principle:
The capacity to diffuse oxygen decreases with age and results in a lower level of oxygen in the arterial circulation ; Page# 488
Principle:
Stridor is the sound of a partial upper airway obstruction and should be reported immediately! ; Page# 489
Principle:
Surfactant prevents atelectasis during exhalation and promotes lung function ; Page# 483
Principle:
Surgery increases ones risk for venous thromboembolism, surgical site infection, cardiovascular and respiratory complications. ; Page# 417
Principle:
Symptoms of alcohol withdrawal may occur 2-4 days following the last drink ; Page# 422
The nurse is caring for a client with severe aortic stenosis. Which assessment finding is consistent with this disorder? Answer Options * A creatinine of 0.8 mg/ dL Polyuria + 4 Peripheral pulse Systolic murmur
Systolic murmur -S4 heart sound
Principle:
Tachycardia and muscle rigidity are early signs of malignant hyperthermia ; Page# 450
Principle
Tachypnea may be one of the first signs signaling a need for oxygen therapy ; Page#
Principle:
Tachypnea may be one of the first signs signaling a need for oxygen therapy ; Page# 488
Principle:
Tachypnea may be one of the first signs signaling a need for oxygen therapy ; Page# 502
Principle:
Teach signs and symptoms of infection prior to discharge since many postoperative infections are not evident until after discharge! ; Page# 458
Principle:
The cough reflex helps to remove secretions and protect the lungs from foreign bodies. ; Page# 488
Principle:
The elderly have a greater risk for hypothermia ; Page# 460
Principle:
The elderly have a greater risk of complications following surgery due to lower cardiac reserve and depressed renal and liver function. ; Page# 460
Principle:
The first postoperative dressing is changed by the surgeon ; Page# 468
Prepare for intubation and mechanical ventilation.
The lab calls the unit with the client's arterial blood gas levels: pH 7.30, paO2 47 mmHg, paCO2 55 mmHg, HCO3 29mEq/L. Which of the following is the nurse's priority intervention? Answer Options * Repeat the arterial blood gas levels. Prepare for intubation and mechanical ventilation. Administer a bronchodilator. Obtain pulse oximetry readings
'To help determine the dosing of the drug and how often you should receive it.'
The lab calls to report the peak and trough levels on the client receiving intravenous (IV) vancomycin. The client wants to know why these levels were drawn. Which of the following is the nurse's best response? Answer Options * 'To prevent side effects like flushing and redness that's caused by this medication.' 'To help determine the dosing of the drug and how often you should receive it.' 'To provide information on how fast a rate we can administer the drug.' 'To help with the selection of which type of drug will help you get well.'
Restlessness Tachycardia Complaints of dyspnea
The laboratory calls to report a client's arterial blood gas levels as pH 7.31, pCO2 49, HCO3 28 and PaO2 74. Which of the following clinical manifestations support this finding? Select all that apply Answer Options * Complaints of dyspnea Nausea and vomiting Tachycardia Restlessness Watery diarrhea
Client has a dark-skinned complexion Client is anemic Client is wearing blue nail polish
The licensed practical nurse reports a client's pulse oximetry (SpO2) reading to the nurse of 88%. As the nurse assesses the client, which of the following factors may have affected the accuracy of the pulse oximetry reading? Select all that apply. Answer Options * Client has hypertension Client has a dark-skinned complexion Client is anemic Client is wearing blue nail polish Client has diabetes
Principle:
The negative pressure of the lungs allows air to enter in; the lungs can collapse if this pressure is loss ; Page# 539
Respiratory rate 28 Restlessness Dyspnea
The nurse assesses the need for oxygen therapy in the client presenting to the emergency department (ED). Which of the following physical findings would indicate the need for oxygen therapy? Select all that apply. Answer Options * Respiratory rate 28 Restlessness Dyspnea Blood pressure 130/80 Oxygen saturation of 95%
Hyperkalemia occurs with acidosis
The nurse educator is preparing an inservice on acid base imbalances for junior level nurses. Which of the following concepts should the nurse educator include in the session? Answer Options * Diarrhea contributes to alkalosis Hypoglycemia causes acidosis Hyperkalemia occurs with acidosis Respiratory depression contributes to alkalosis
Gently milk the tubing in the direction of the drainage chamber
The nurse is caring for a client with a chest tube and notices that the tubing appears to be obstructed with clots and fibrin. Which action should the nurse take next ? Answer Options * Disconnect the tubing from the chest drainage system and replace the system Clamp the chest tube immediately and report the finding to the primary care provider Gently milk the tubing in the direction of the drainage chamber Instruct the client to deep breath and cough every two hours
Auscultate bilateral breath sounds.
The nurse is caring for a client with a chest tube connected to a closed drainage system. The nurse notes that tidaling has stopped in the water compartment. What is the nurse's next action? Answer Options * Activate the emergency response system. Notify the health care provider. Auscultate bilateral breath sounds. Obtain arterial blood gas levels.
Monitor client's vital signs frequently Elevate the head of bed 30-40 degrees Instruct client to cough and deep breath Position the client onto the left side
The nurse is caring for a client with bronchiectasis who had a left pneumonectomy. Which of the following interventions would be included in the client's care plan? Select all that apply. Answer Options * Monitor client's vital signs frequently Elevate the head of bed 30-40 degrees Instruct client to cough and deep breath Position the client onto the left side Splint the abdomen when breathing deeply
Bronchial breath sounds in peripheral lung fields Crackles in affected areas Egophony
The nurse is caring for a client with pneumonia. Which of the following clinical findings should the nurse expect with this condition? Select all that apply. Answer Options * Bronchial breath sounds in peripheral lung fields Crackles in affected areas Decrease in fremitus Egophony Stridor
Sudden severe dyspnea
The nurse is caring for a client with viral pneumonia. The nurse notes signs that the client may be developing acute respiratory distress syndrome (ARDS). Which of the following clinical signs are consistent with the development of ARDS? Answer Options * Oxygen saturation 95% Sudden severe dyspnea Jugular vein distention Kussmaul respirations
A 29-year-old with an hemoglobin A1c of 9%
The nurse is caring for several clients who are scheduled to have a lower extremity surgical procedure. When developing their plan of care, the nurse knows that which one of the following clients has the highest risk for a surgical site infection (SSI)?
Hypoxia affecting neurological status
The nurse is caring for the post-surgical client who is restless and suddenly expresses a feeling of impending doom. Assessment findings also include dyspnea, tachypnea, and tachycardia. Which of the following best describes the underlying reason for the client's presentation? Answer Options * Structural abnormalities Inflammatory response Hypoxia affecting neurological status Conduction irregularities
Obtain the arterial blood gas level
The nurse is completing an assessment on the pregnant client with a pulmonary embolus. The nurse identifies a nursing diagnosis of altered gas exchange. Which intervention should be included in the nursing plan of care? Answer Options * Check the peak expiratory flow rate Assess brain natriuretic peptide level Obtain the arterial blood gas level Administer a metered dose inhaler
Recognizing signs and symptoms of infection
The nurse is preparing a client who had an appendectomy for discharge. Which instruction given by the nurse is a priority? Answer Options * Recognizing signs and symptoms of infection Increasing fluids to prevent constipation Actions to take for a wound dehiscense Ambulating to prevent constipation
Urinate after intercourse, Change incontinence pads frequently
The nurse is preparing an inservice on measures to decrease the risk for infection for members of an assisted living facility. The nurse includes which of the following interventions? Answer Options * Limit fluid intake Avoid the use of lotion Change incontinence pads frequently Urinate after intercourse Obtain the pneumococcal vaccine annually
Infection Electrolyte imbalances Delayed wound healing
The nurse is preparing to administer prednisone to the client. The nurse understands this medication puts the client at risk for which of the following adverse effects? Select all that apply. Answer Options * Hypotension Infection Electrolyte imbalances Hypoglycemia Delayed wound healing
Perform hand hygiene Turn on suction source to 120 mmHg Hyperoxygenate prior to suctioning
The nurse is preparing to suction a client with a tracheostomy tube using an open system. Which of the following actions would the nurse take ?
Getting the client out of bed to ambulate with assistance. Having around-the-clock pain medication made available. Splinting the incision when coughing and deep breathing.
The nurse is providing preoperative teaching to the client scheduled for abdominal surgery. Which key points would the nurse include to help the client prevent complications from surgery? Select all that apply. Answer Options * Getting the client out of bed to ambulate with assistance. Importance of high fiber foods as soon as surgery is completed. Having around-the-clock pain medication made available. Splinting the incision when coughing and deep breathing. Using the incentive spirometry every 4 hours while awake.
Advocate for the use of a patient-controlled analgesia (PCA) pump for more timely dosing
The nurse is receiving a client from the post-op recovery unit who had a cholecystectomy two hours ago. To avoid complications from pain, the nurse should perform which intervention? Answer Options * Verify the physician's order and ensure pain medications are only administered prn Assess the client's pain level every 15 minutes in an effort to prevent breakthrough pain Advocate for the use of a patient-controlled analgesia (PCA) pump for more timely dosing Encourage bedrest while using narcotic analgesics to decrease the risk for falls
Change positions slowly when getting up from your seat
The nurse is teaching a client who is on antihypertensive medications on how to avoid episodes of orthostatic hypotension. Which key point does the nurse include in the client's education? Answer Options * Take the medication at the same time each day Consume alcohol 30 minutes after taking the medication Change positions slowly when getting up from your seat Limit dietary intake of sodium to 1750 mg/day
Encourage deep breathing exercises and use of incentive spirometer
The nurse records the vital signs on the postoperative client who had abdominal surgery and complains of pain as follows: Temperature 99 degrees Fahrenheit, Pulse 94 beats/minute, Respirations 12 breaths/minute, Blood Pressure 150/80 mmHg. After medicating the client for pain, which of the following is the priority nursing action for this client? Answer Options * Notify the provider and obtain an order for serum blood cultures Remove the surgical dressing to observe for redness or drainage Encourage deep breathing exercises and use of incentive spirometer Hold next dose of antibiotics until notifying the health care provider
Apprehension
The nurse suspects hypoxemia in a client who has a change in their respiratory rate. Which of the following physical findings would be the earliest indicator of this change in the client? Answer Options * Cyanosis Diaphoresis Clubbing of nail beds Apprehension
PaO2 of 75 mm Hg
The nurse suspects hypoxia in a client who presents to the emergency department (ED) with dyspnea. The nurse recognizes which of the following as the most reliable indicator of hypoxia? Answer Options * Cold clammy skin Respiratory rate 26 breaths/ minute Cyanosis PaO2 of 75 mm Hg
The client has voluntarily signed the form.
The nurse witnesses that a client has signed an informed consent. Which statement best explains what the nurses signature means? Answer Options * The client has voluntarily signed the form. The client understands all of the nurse's instructions. The client knows that the nurse will reinforce the teachings. The client is aware of the client's bill of rights.
Obtain urine cultures.
The older adult client with an indwelling catheter is transferred from a nursing home. The client complains of urinary frequency and burning. Which of the following interventions that the health care provider orders should the nurse perform first? Answer Options * Start an intravenous line. Start oral ciprofloxacin. Transfer from bed to chair. Obtain urine cultures.
Decreased levels of oxygen in the arterial circulation
The older adult client with congestive heart failure (CHF) returns to the unit after having a chest x-ray and bronchoscopy. The nurse knows that which of the following occurs in the elderly? Answer Options * Structural deformities that lead to a barrel chest Intermittent episodes of apnea when sleeping Decreased levels of oxygen in the arterial circulation Hypersensitive gag reflex that increases risk for pneumonia
Determining whether the client has taken any aspirin products
Which of the following actions by the nurse is a priority when preparing a client for surgery? Answer Options * Assessing when the client had the last bowel movement Asking about transportation needs for follow up appointments Determining whether the client has taken any aspirin products Providing time for the client to discuss any fears or
Inflate the tracheostomy cuff before and for 30 minutes after each feeding
The respiratory status of a client with Guillain-Barre syndrome has progressively deteriorated and a tracheostomy is performed. Nasogastric tube feedings are ordered. The nurse would: Answer Options * Deflate the tracheostomy cuff to prevent laryngeal irritation and swelling Deflate the tracheostomy cuff so the client can breathe during the feeding Inflate the tracheostomy cuff after the tube feeding has been completed Inflate the tracheostomy cuff before and for 30 minutes after each feeding
Principle
The retention of carbon dioxide could lead to respiratory acidosis ; Page# 486
Principle:
The retention of carbon dioxide could lead to respiratory acidosis ; Page# 486
Left or right side
Which position should the nurse place an immobile client who is in the process of vomiting?
Position onto the side to help prevent aspiration
Which rationale best describes the position a nurse should place the client in during a severe vomiting episode? Answer Options * Position in a semi-Fowlers position to improve gas exchange Position onto the side to help prevent aspiration Position in a high-fowlers position to allow for deep breathing Position in a prone position to prevent complications
Assess the client's breathing and administer oxygen via nasal cannula
The unlicensed assistive personnel (UAP) reports to the nurse that a client is very short of breath, anxious, and restless. Which action should the registered nurse take next? Answer Options * Instruct the UAP to administer oxygen 2L/ min nasal cannula Assess the client's breathing and administer oxygen via nasal cannula Place the client in a trendelenberg position and instruct on deep breathing Have the licensed practical nurse assess the condition and obtain vital signs
Principle
The use of accessory muscles during rest could be indicative of disease ; Page# 495
Principle:
The use of accessory muscles during rest could be indicative of disease ; Page# 495
Principle:
Tidaling in the water seal chamber of a traditional water seal chest drainage system indicates a secure connection ; Page# 541
Principle:
Tilt the head back and pull the lower jaw forward to open the airway during pharyngeal obstruction ; Page# 458
The earlobes
To detect cyanosis in the client with a darker colored skin, the nurse should assess which of the following areas? Answer Options * The earlobes The nailbeds The sclera The antecubital space
Absence of wheezing
Treatment for status asthmaticus may include the administration of magnesium sulfate. How should the nurse determine if treatment was effective? Answer Options * Use of accessory muscles Verbalizing less pain Increase in respirations Absence of wheezing
Principle:
Turn patients to their side when vomiting ; Page# 450
Principle:
Turn the client onto their side to prevent aspiration from vomitus ; Page# 458
The client presents to the emergency department (ED) with chest trauma. The nurse should assess for which of the following clinical signs of pneumothorax? Answer Options * Pink, frothy sputum Barrel-shaped chest Unequal lung expansion Clubbing to the nail beds
Unequal lung expansion
Principle:
Urinary output decreases with hemorrhage ; Page# 459
Principle:
Use approved translators whenever possible; family members should NOT be used as translators ; Page# 422
Principle
Use suction pressure no greater than 120 mm Hg for an open system ; Page#
Principle
Vagal stimulation can be caused by vomiting, suctioning, or severe pain and results in bradycardia! ; Page# 522
Principle:
Valve disorders contribute to turbulent blood flow and heart murmurs ; Page# 690
Principle:
Verifying the surgical procedure, site and patient identity are priority actions! ; Page# 440
Principle:
Visual inspection of respirations does NOT equate to adequate ventilation! ; Page# 501
Principle:
Volume replacement is a nursing priority during hypovolemic shock ; Page# 459
Principle:
Weight loss and fatigue are cardinal signs of malignancy ; Page# 1418
Principle:
Wheezing is a sign of lower airwary narrowing ; Page# 654
Verification of the surgical procedure, operative site and client identity
Which safety measure is a priority for a client who is scheduled for orthopedic surgery? Answer Options * Documentation of the designated caregiver's contact information Administration of antibiotic at least 20 minutes prior to the procedure Verification of the surgical procedure, operative site and client identity Lab confirmation that a minimum of 2 units of O- blood is available
Principle:
Witness the signing of the consent and clarify what the surgeon stated ; Page# 422
The nurse is caring for a client with a chest tube connected to a closed drainage system. The nurse notes that tidaling has stopped in the water compartment. What is the nurse's next action? Answer Options * Activate the emergency response system. Notify the health care provider. Auscultate bilateral breath sounds. Obtain arterial blood gas levels.
Your Answer: Auscultate bilateral breath sounds.
Leaving the room momentarily to assess the needs of another client.
When caring for a client who is receiving conscious sedation, which action by the nurse is considered unsafe practice? Answer Options * Titrating oxygen flow rate through nasal cannula during the procedure. Monitoring client's blood pressure every 5 minutes while under sedation. Administering ordered flumazenil (Romazicon) for reversals if needed. Leaving the room momentarily to assess the needs of another client.
Decreased surfactant secretion.
When caring for a client with acute respiratory distress syndrome (ARDS), the nurse knows the client is at increased risk for atelectasis for which of the following reasons? Answer Options * Increased air trapping. Decreased surfactant secretion. Increased mucous production. Decreased oxygen from obstruction.
Checking the vital signs every 15 minutes for the first hour
When developing a plan of care for a client who has returned from surgery, the nurse should anticipate performing which of the following actions Answer Options * Checking the gag reflex if the client coughs after drinking water Checking the vital signs every 15 minutes for the first hour Keeping the client NPO for 4 hours before and after the procedure Keeping the client in a supine position for a minimum of 4 hours
Principle
When glucose metabolism is reduced metabolic acidosis may occur ; Page# 450
Principle:
When obtaining a peak and trough, the trough is collected just before the infusion and the peak is obtained 30 - 60 minutes after the infusion ends. ; Page#
Monitor the client frequently
When planning for a client's care during the detoxification phase of acute alcohol withdrawal, the nurse anticipates the need to Answer Options * Monitor the client frequently Keep the client's environment bright Address the client in a loud, clear voice Physically restrain the client if agitated
Raise the side rails of the client's bed to a full and locked upward position.
Which action by the nurse provides the most safety for a client who just received pre-anesthetic medications? Answer Options * Ask a family member to stay with the client until called to the operating suite. Raise the side rails of the client's bed to a full and locked upward position. Have the client initial the surgical consent form within the next half hour. Immediately place a Foley catheter in the client and record urinary output.
Hyperextension of the head while gently pulling the jaw forward
Which action should the nurse take to open the client's airway during a pharyngeal obstruction? Answer Options * Flexion of the head while the client is placed in a supine position Hyperextension of the head while the client raises up their arms Hyperextension of the head while gently pulling the jaw forward Flexion of the head with the client leans over the bedside table.
Bilateral wheezing
Which assessment finding is the nurse most likely to observe in a client who just experienced aspiration following surgery? Answer Options * Lungs clear to ausculation Diminished cough reflex Bilateral wheezing Decrease in chest rising
A 65--old client who has a creatinine of 3.9
Which client is most likely to have a post surgical complication? Answer Options * A 74-year-old client who quit smoking 1 year ago A 65-year-old client who has a creatinine of 3.9 A 79-year-old client with a history of dementia A 60-year-old client who didn't get the flu shot
