HEMATOLOGY
1. You are reviewing the complete blood count (CBC) for a client who has been
admitted for knee arthroscopy. Which value is most important to report to the
physician prior to surgery? White blood cell count 16,000/mm3
2. A new RN is preparing to administer packed red blood cells (PRBCs) to a
client whose anemia was caused by blood loss after surgery. Which action by
the new RN requires that you, as charge nurse, intervene immediately?
The new RN primes the transfusion set using 5% dextrose in lactated Ringer’s
solution.
3. A 32-year-old client with a history of sickle cell anemia is admitted to the
hospital during a sickle cell crisis. The physician orders all of these interventions.
Which order will you implement first? Administer oxygen at an F102 of 100% per
non-rebreather mask.
4. A 78-year-old client admitted to the hospital with chronic anemia caused by
possible gastrointestinal bleeding has all of these activities included in the care
plan. Which activity is best delegated to an experienced nursing assistant (NA)?
Use Hemoccult slides to obtain stool specimens.
5. As charge nurse, you are making the daily assignments on the medicalsurgical unit. Which client is best assigned to a nurse who has floated from the
post-anesthesia care unit (PACU)?
A 52-year-old client with chronic gastrointestinal bleeding who has returned to
the unit after a colonoscopy
6. You are making a room assignment for a newly arrived client whose
laboratory testing indicates pancytopenia. All of these clients are already on the
nursing unit. Which one will be the best roommate for the new client? The client
with digoxin toxicity
7. A client admitted to the hospital with a sickle cell crisis complains of severe
abdominal, hip, and knee pain. You observe an LPN accomplishing these client
care tasks. Which one requires that you, as charge nurse, intervene
immediately? The LPN positions cold packs on the client’s knees.
8. A 67-year-old client who is receiving chemotherapy for lung cancer is
admitted to the hospital with thrombocytopenia. While you are taking the
admission history, the client makes these statements. Which statement is of most
concern?
“I take one aspirin every morning because of my history of angina.”
9. Following a car accident, a client with a Medic-Alert bracelet indicating
hemophilia A is admitted to the emergency department (ED). Which physician
order should you implement first? Transfuse Factor VII concentrate.
10.As home health nurse, you are taking an admission history for a client who
has a deep vein thrombosis and is taking warfarin (Coumadin) 2 mg daily.
Which statement by the client is the best indicator that additional teaching
about warfarin may be needed? “I have started to eat more healthy foods like
green salads and fruit.”
11.A client is admitted to the intensive car unit (ICU) with disseminated
intravascular coagulation (DIC) associated with a gram-negative infection.
Which assessment information has the most immediate implications for the
client’s care?
The client’s oxygen saturation is 87%
12. A 22-year-old with stage I Hodgkin’s disease is admitted to the oncology unit
for radiation therapy. During the initial assessment, the client tells you,
“Sometimes I am afraid of dying.” Which response is most appropriate at this
time?
“Tell me a little bit more about your fear of dying.”
13.After receiving change-of-shift report about all of these clients, which one will
you assess first?
A 69-year-old with chemotherapy-induced neutropenia who has an elevated
oral temperature
14.A long-term-care client with chronic lymphocytic leukemia has a nursing
diagnosis of Activity Intolerance related to weakness and anemia. Which of
these nursing activities is most appropriate for you, as the charge nurse, to
delegate to a nursing assistant? Check the client’s blood pressure and pulse rate
after ambulation.
15.A transfusion of PRBCs has been infusing for 5 minutes when the client
becomes flushed and tachypneic and says, “I am having chills. Please get me a
blanket.” Which action should you take first? Stop the medication.
16.A group of clients is assigned to an RN-LPN/LVN team. The LPN/LVN is most
likely to be assigned to provide client care and administer medications to which
of these clients?
A 36-year-old client with chronic renal failure who will need a subcutaneous
injection of epoetin (Procrit)
17. You obtain the following data about a client admitted with multiple
myeloma. Which information has the most immediate implications for the client’s
care? The client is unable to plantarflex the feet.
18.The nurse in the outpatient clinic is assessing a 22-year-old with a history of a
recent splenectomy after a motor vehicle accident. Which information obtained
during the assessment will be of most immediate concern to the nurse?
The client has an oral temperature of 99.7o F
19.A client with graft-versus-host disease (GVHD) after a bone marrow transplant
is being cared for on the medical unit. Which of these nursing activities is best
delegated to a newly graduated RN who has had a 6-week orientation to the
unit?
Infusion of D5.45% normal saline at 125 mL/hour to the client
20.You are the charge nurse in an oncology unit. A client with an absolute
neutrophil count (ANC) of 300/mm3 is placed in protective isolation. Which staff
member should you assign to provide care for this client, under the supervision
of an experienced oncology RN? An LPN with 2 years of experience on the
oncology unit
21.You are transferring a client with newly diagnosed chronic myeloid leukemia
to a long-term-care (LTC) facility. Which information is most important to the LTC
charge nurse prior to transferring the client? The client’s chemotherapy has
resulted in neutropenia
22.A client with acute myelogenous leukemia is receiving induction phase
chemotherapy. Which assessment information is of most concern? Serum
potassium level of 7.8 mEq/L
23.A client who has been receiving cyclosporine following an organ transplant is
experiencing these symptoms. Which one is of most concern? Non-tender
swelling in the right groin
24.You have developed the nursing diagnosis Risk for Impaired Tissue Integrity
related to effects of radiation for a client with Hodgkin’s lymphoma who is
receiving radiation to the groin area. Which nursing activity is best delegated to
a nursing assistant caring for the client? Clean the skin over daily with a mild
soap.
25.After receiving the change-of-shift report, which client will you assess first? A
20-year-old with possible acute myelogenous leukemia who has just arrived on
the medical unit
26. The nurse is preparing to teach a client with microcytic hypochromic anemia
about the diet to follow after discharge. Which of the following foods should be
included in the diet?
Eggs
27. The nurse would instruct the client to eat which of the following foods to
obtain the best supply of vitamin B12?
Meats and dairy products
28. The nurse has just admitted a 35-year-old female client who has a serum B12
concentration of 800 pg/ml. Which of the following laboratory findings would
cue the nurse to focus the client history on specific drug or alcohol abuse?
Folate, 1.5 ng/mL
29. The nurse understands that the client with pernicious anemia will have which
distinguishing laboratory findings?
Intrinsic factor, absent.
30. The nurse devises a teaching plan for the patient with aplastic anemia.
Which of the following is the most important concept to teach for health
maintenance?
Avoid exposure to others with acute infection
31. A client comes into the health clinic 3 years after undergoing a resection of
the terminal ileum complaining of weakness, shortness of breath, and a sore
tongue. Which client statement indicates a need for intervention and client
teaching? “I take a vitamin B12 tablet every day.”
32. A vegetarian client was referred to a dietician for nutritional counseling for
anemia. Which client outcome indicates that the client does not understand
nutritional counseling? The client:
Drinks coffee or tea with meals
33. A client was admitted with iron deficiency anemia and blood-streaked
emesis. Which question is most appropriate for the nurse to ask in determining
the extent of the client’s activity intolerance? “What activities were you able to
do 6 months ago compared with the present?”
34.The primary purpose of the Schilling test is to measure the client’s ability to:
Absorb vitamin B12
35. The nurse implements which of the following for the client who is starting a
Schilling test? Starting a 24- to 48 hour urine specimen collection
36. A client with pernicious anemia asks why she must take vitamin B12
injections for the rest of her life. What is the nurse’s best response? “The reason
for your vitamin deficiency is an inability to absorb the vitamin because the
stomach is not producing sufficient intrinsic factor.”
37. The nurse is assessing a client’s activity intolerance by having the client walk
on a treadmill for 5 minutes. Which of the following indicates an abnormal
response?
Respiratory rate decreased by 5 breaths/minute
38. When comparing the hematocrit levels of a post-op client, the nurse notes
that the hematocrit decreased from 36% to 34% on the third day even though
the RBC and hemoglobin values remained stable at 4.5 million and 11.9 g/dL,
respectively. Which nursing intervention is most appropriate?
Continue to monitor vital signs
39. A client is to receive epoetin (Epogen) injections. What laboratory value
should the nurse assess before giving the injection? Hematocrit
40. A client states that she is afraid of receiving vitamin B12 injections because
of the potential toxic reactions. What is the nurse’s best response to relieve these
fears?
“Vitamin B12 is generally free of toxicity because it is water soluble.”
41. A client with microcytic anemia is having trouble selecting food items from
the hospital menu. Which food is best for the nurse to suggest for satisfying the
client’s nutritional needs and personal preferences? Brown rice
42. A client with macrocytic anemia has a burn on her foot and states that she
had been watching television while lying on a heating pad. What is the nurse’s
first response?
Check for diminished sensations
43. Which of the following nursing assessments is a late symptom of
polycythemia vera? Pruritus
44. The nurse is teaching a client with polycythemia vera about potential
complications from this disease. Which manifestations would the nurse include in
the client’s teaching plan? Select all that apply.
1. Visual disturbance
2. Headache
3. Orthopnea
4. Gout
45. When a client is diagnosed with aplastic anemia, the nurse monitors for
changes in which of the following physiological functions? Bleeding tendencies
46. Which of the following blood components is decreased in anemia?
Erythrocytes
47. A client with anemia may be tired due to a tissue deficiency of which of the
following substances?
Oxygen
48. Which of the following cells is the precursor to the red blood cell (RBC)?
Stem cell
49. Which of the following symptoms is expected with hemoglobin of 10 g/dl?
None
50. Which of the following diagnostic findings are most likely for a client with
aplastic anemia? Decreased levels of white blood cells, red blood cells, and
platelets
51. A client with iron deficiency anemia is scheduled for discharge. Which
instruction about prescribed ferrous gluconate therapy should the nurse include
in the teaching plan? “Take the medication on an empty stomach.”
52. Which of the following disorders results from a deficiency of factor VIII?
Hemophilia A
53. The nurse explains to the parents of a 1-year-old child admitted to the
hospital in a sickle cell crisis that the local tissue damage the child has on
admission is caused by which of the following? Obstruction to circulation
54. The mothers asks the nurse why her child’s hemoglobin was normal at birth
but now the child has S hemoglobin. Which of the following responses by the
nurse is most appropriate? “The newborn has a high concentration of fetal
hemoglobin in the blood for some time after birth.”
55. Which of the following would the nurse identify as the priority nursing
diagnosis during a toddler’s vasoocclusive sickle cell crisis? Pain related to
tissue anoxia
56. A mother asks the nurse if her child’s iron deficiency anemia is related to the
child’s frequent infections. The nurse responds based on the understanding of
which of the following? Children with iron deficiency anemia are more
susceptible to infection than are other children.
57. Which statements by the mother of a toddler would lead the nurse to
suspect that the child has iron-deficiency anemia? Select all that apply.
1. “He drinks over 3 cups of milk per day.”
2. “I can’t keep enough apple juice in the house; he must drink over 10
ounces per day.”
58. Which of the following foods would the nurse encourage the mother to offer
to her child with iron deficiency anemia?
Potato, peas, and chicken
59. The physician has ordered several laboratory tests to help diagnose an
infant’s bleeding disorder. Which of the following tests, if abnormal, would the
nurse interpret as most likely to indicate hemophilia? Partial thromboplastin time
(PTT)
60. Which of the following assessments in a child with hemophilia would lead
the nurse to suspect early hemarthrosis? Child’s reluctance to move a body part
61. Because of the risks associated with administration of factor VIII
concentrate, the nurse would teach the client’s family to recognize and report
which of the following?
Yellowing of the skin
62. A child suspected of having sickle cell disease is seen in a clinic, and
laboratory studies are performed. A nurse checks the lab results, knowing that
which of the following would be increased in this disease? Reticulocyte count
63. A clinic nurse instructs the mother of a child with sickle cell disease about
the precipitating factors related to pain crisis. Which of the following, if identified
by the mother as a precipitating factor, indicates the need for further
instructions?
Fluid overload
64. Laboratory studies are performed for a child suspected of having iron
deficiency anemia. The nurse reviews the laboratory results, knowing that which
of the following results would indicate this type of anemia? Red blood cells that
are microcytic and hypochromic
65. A pediatric nurse health educator provides a teaching session to the nursing
staff regarding hemophilia. Which of the following information regarding this
disorder would the nurse plan to include in the discussion? Hemophilia A results
from a deficiency of factor VIII
NEUROLOGICAL
1. Regular oral hygiene is an essential intervention for the client who has had a
stroke. Which of the following nursing measures is inappropriate when providing
oral hygiene?
Placing the client on the back with a small pillow under the head.
2. A 78-year-old client is admitted to the emergency department with numbness
and weakness of the left arm and slurred speech. Which nursing intervention is a
priority? Schedule for A STAT computer tomography (CT) scan of the head.
3. A client arrives in the emergency department with an ischemic stroke and
receives tissue plasminogen activator (t-PA) administration. Which is the priority
nursing assessment? Time of onset of current stroke.
4. During the first 24 hours after thrombolytic therapy for ischemic stroke, the
primary goal is to control the client’s: Blood pressure
5. What is a priority nursing assessment in the first 24 hours after admission of the
client with a thrombotic stroke?
Pupil size and pupillary response
6.What is the expected outcome of thrombolytic drug therapy?
Dissolved emboli
7. The client diagnosed with atrial fibrillation has experienced a transient
ischemic attack (TIA). Which medication would the nurse anticipate being
ordered for the client on discharge?
An oral anticoagulant medication
8. Which client would the nurse identify as being most at risk for experiencing a
CVA? A 55-year-old African American male.
9. Which assessment data would indicate to the nurse that the client would be at
risk for a hemorrhagic stroke?
A blood pressure of 220/120 mmHg.
10. Question 10
The nurse and unlicensed assistive personnel (UAP) are caring for a client with
right-sided paralysis. Which action by the UAP requires the nurse to intervene?
The assistant places her hand under the client’s right axilla to help him/her move
up in bed.
11. Question 11
A client admitted to the hospital with a subarachnoid hemorrhage has
complaints of severe headache, nuchal rigidity, and projectile vomiting. The
nurse knows lumbar puncture (LP) would be contraindicated in this client in
which of the following circumstances?
Intracranial pressure (ICP) is increased.
12. A client with a subdural hematoma becomes restless and confused, with
dilation of the ipsilateral pupil. The physician orders mannitol for which of the
following reasons?
To promote osmotic diuresis to decrease ICP.
13. A client with subdural hematoma was given mannitol to decrease
intracranial pressure (ICP). Which of the following results would best show the
mannitol was effective?
Urine output increases.
14. Which of the following values is considered normal for ICP? 0 to 15 mm Hg
15. Question 15
Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?
Ataxia and confusion
16. Which of the following signs and symptoms of increased ICP after head
trauma would appear first?
Restlessness and confusion
17. Problems with memory and learning would relate to which of the following
lobes? Temporal
18. While cooking, your client couldn’t feel the temperature of a hot oven. Which
lobe could be dysfunctional? Parietal
19. The nurse is assessing the motor function of an unconscious client. The nurse
would plan to use which of the following to test the client’s peripheral response
to pain?
Nail bed pressure
20. The client is having a lumbar puncture performed. The nurse would plan to
place the client in which position for the procedure? Side-lying, with legs pulled
up and head bent down onto the chest.
21. A nurse is assisting with caloric testing of the oculovestibular reflex of an
unconscious client. Cold water is injected into the left auditory canal. The client
exhibits eye conjugate movements toward the left followed by a rapid
nystagmus toward the right. The nurse understands that this indicates the client
has: An intact brainstem
22. The nurse is caring for the client with increased intracranial pressure. The
nurse would note which of the following trends in vital signs if the ICP is rising?
Increasing temperature, decreasing pulse, decreasing respirations, increasing
blood pressure.
23. The nurse is evaluating the status of a client who had a craniotomy 3 days
ago. The nurse would suspect the client is developing meningitis as a
complication of surgery if the client exhibits: A positive Brudzinski’s sign.
24. A client is arousing from a coma and keeps saying, “Just stop the pain.” The
nurse responds based on the knowledge that the human body typically and
automatically responds to pain first with attempts to: Escape the source of pain.
25. The nurse is assessing a child diagnosed with a brain tumor. Which of the
following signs and symptoms would the nurse expect the child to demonstrate?
Select all that apply.
○ A. Increased appetite
○ B. Vomiting
○ C. Polydipsia
○ D. Lethargy
○ E. Head tilt
26. A lumbar puncture is performed on a child suspected of having bacterial
meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF
analysis and determines which of the following results would verify the
diagnosis?
Cloudy CSF, elevated protein, and decreased glucose.
27. A nurse is planning care for a child with acute bacterial meningitis. Based on
the mode of transmission of this infection, which of the following would be
included in the plan of care? Maintain respiratory isolation precautions for at
least 24 hours after the initiation of antibiotics.
28. You are preparing to admit a patient with a seizure disorder. Which of the
following actions can you delegate to LPN/LVN?
Set up oxygen and suction equipment.
29. If a male client experienced a cerebrovascular accident (CVA) that
damaged the hypothalamus, the nurse would anticipate that the client has
problems with:
Body temperature control
30. A female client admitted to an acute care facility after a car accident
develops signs and symptoms of increased intracranial pressure (ICP). The client
is intubated and placed on mechanical ventilation to help reduce ICP. To
prevent a further rise in ICP caused by suctioning, the nurse anticipates
administering which drug endotracheally before suctioning?
lidocaine (Xylocaine)
31. After striking his head on a tree while falling from a ladder, a young man age
18 is admitted to the emergency department. He’s unconscious and his pupils
are nonreactive. Which intervention would be the most dangerous for the client?
Perform a lumbar puncture.
32. When obtaining the health history from a male client with retinal detachment,
the nurse expects the client to report:
Light flashes and floaters in front of the eye.
33. Which nursing diagnosis takes highest priority for a client with Parkinson’s
crisis? Ineffective airway clearance
34. The nurse has given the male client with Bell’s palsy instructions on preserving
muscle tone in the face and preventing denervation. The nurse determines that
the client needs additional information if the client states that he or she will:
Exposure to cold and drafts.
35. A female client is admitted to the hospital with a diagnosis of Guillain-Barre
syndrome. The nurse inquires during the nursing admission interview if the client
has a history of:
Respiratory or gastrointestinal infection during the previous month.
36. A female client with Guillain-Barre syndrome has ascending paralysis and is
intubated and receiving mechanical ventilation. Which of the following
strategies would the nurse incorporate in the plan of care to help the client cope
with this illness? Providing information, giving positive feedback and
encouraging relaxation.
37 A male client has an impairment of cranial nerve II. Specific to this
impairment, the nurse would plan to do which of the following to ensure the
client to ensure client safety?
Provide a clear path for ambulation without obstacles.
38. A female client has a neurological deficit involving the limbic system.
Specific to this type of deficit, the nurse would document which of the following
information related to the client’s behavior. Affect is flat, with periods of
emotional lability.
39. A client is admitted to the emergency room with a spinal cord injury. The
client is complaining of lightheadedness, flushed skin above the level of the
injury, and headache. The client’s blood pressure is 160/90 mm Hg. Which of the
following is a priority action for the nurse to take?
Raise the head of the bed
40. A client who had a stroke is seen bumping into things on the side and is
having difficulty picking up the beginning of the next line of what he is reading.
The client is experiencing which of the following conditions?
Homonymous Hemianopsia
41. Which of the following medical treatments should the nurse anticipate
administering to a client with increased intracranial pressure due to brain
hemorrhage, except? Nitroglycerin (Nitrostat)
42. Which of the following symptoms would you expect to a client with a
phenytoin level of 35 mg/dL? Ataxia
RESPI
A client with asthma has pronounced wheezing upon auscultation. suspecting
an impending asthma attack, a nurse should
have the client cough and deep breath
prepare to intubate the client
prepare to administer a nebulized beta-2 adrenergic agonist
have the client lay on his or her right side
Definition
prepare to administer a nebulized beta-2 adrenergic agonist
Term
a client newly diagnosed with asthma is preparing for discharge. which point
should a nurse emphasize during the client's teaching
contact care provider only if nighttime wheezing becomes a concern
limit exposure to sources that trigger an attack
use peak flow meter only if symptoms are worsening
use inhaled steroid medication as a rescue inhaler
Definition
limit exposure to sources that trigger an attack
Term
a nurse is working with a client to update the client's asthma action plan. the nurse
knows that this action plan should include information on
medication adjustments that should made if peak flow is less than 50% normal
timeline for allergy skin testing
the most direct route when the client drives to the hospital
the best methods for chest physiotherapy
Definition
medication adjustments that should made if peak flow is less than 50% normal
Term
a client learning about COPD self care at a community health class aska a nurse
why the participants are being taught about the lip breathing. the nurse should
respond by explaining that pursed lip breathing can help to
reduce upper airway inflammation
reduce anxiety through humor
strengthen respiratory muscles
increase effectiveness of inhaled medication
Definition
strengthen respiratory muscles
Term
which finding should a nurse expect when completing an assessment on a client
with chronic bronchitis
minimal sputum with cough
pink, frothy sputum
barrel chest
stridor on expiration
Definition
barrel chest
Term
a home health nurse is visiting a client whose chronic bronchitis has recently
worsened. which instruction should the nurse reinforce with this client
increase amount of bedrest
increase fluid intake
decrease caloric intake
reduce home oxygen use
Definition
increase fluid intake
Term
a client with COPD is in the thrid postoperative day following right-sided
thoracotomy. during the day shift the client has required 10 L oxygen by mask to
keep his or her oxygen saturations greater than 88%. based on this information
which action should be taken by the evening shift nurse
work to wean oxygen down to 3L by mask
call respiratory therapy for a nebulizer treatment
check respiratory rate and notify the physician
administer dose of ordered pain medication
Definition
check respiratory rate and notify the physician
Term
a client with a suspected pulmonary embolus receives a VQ scan to evaluate
regional lung ventilation of airflow and regional lung blood flow. in consulting with
a physician a nurse learns there is a VQ mismatch. based on this information which
action should be taken by the nurse
tell the client that tuberculosis treatment will be needed
reassure the client that he/she does not have a pulmonary embolism
explain to the client that further testing will be needed
inform the client that the test was normal
Definition
explain to the client that further testing will be needed
Term
a nurse is assessing lung sounds on a client with pneumonia who is having pain
during inspiration and expiration. the nurse hears loud grating sounds over the
lung fields. the nurse should document the client's pain level and should
document that
lung sounds were clear upon auscultation
fine crackles were heard upon auscultation
wheezing was heard upon auscultation
pleural friction rub was heard upon auscultation
Definition
pleural friction rub was heard upon auscultation
Term
a nurse is helping a client with obstructive sleep apnea to apply a CPAP mask
before going to sleep. the nurse knows that the CPAP is intended to
breath for the client during sleep
reduce intrathoracic pressure
deliver high concentrations of oxygen
prevent alveolar collapse
Definition
prevent alveolar collapse
Term
a nurse begins to hear high pressure alarms in the room of a client requiring
respiratory assistance with a ventilator. which is the best action by the nure
wait and allow the client time to regulate breathing in coordination with the
ventilator
check ventilator tubing and connections
silence the alarm and restart the ventilator
lower the tidal volumes being delivered to the client
Definition
check ventilator tubing and connections
Term
a nurse is caring for a client requiring positive pressure mechanical ventilation. the
client has been fighting the ventilator assisted breaths, and the client's blood
pressure has been steadily decreasing. which would be the most appropriate
intervetnion by the nurse
place the client in the prone position
notify the respiratory therapist to increase the positive pressure settings
call the physician to suggest sedatives and paralytics
prepare to administer intravenous aminophylline
Definition
call the physician to suggest sedatives and paralytics
Term
on the third postoperative day following a total laryngectomy a client's family asks
a nurse when the client will be able to eat. which response by the nurse is best.
we are going to start with a feeding tube but eventually he should be able to eat
normally
we are going to start with a feeding tube but eventually he will have to learn a
different way of swallowing to prevent aspiratoin
because of his surgery it will be several more days before his gastrointestinal tract
bbegins functioning again
he will probalby always have to be fed through a gastrostomy tube in his stomach
Definition
we are going to start with a feeding tube but eventually he should be able to eat
normally
Term
a nurse is designing the plan of care for a client following total laryngectomy.
included in the plan of care is a referral to a nutritional support staff/dietician. the
nurse understands that the referral is essential because the client
is most like depressed and uninteresting in eating
will have to relearn how to swallow
may have lost his or her sense of smell and taste
must learn strategies for preventing aspiration
Definition
may have lost his or her sense of smell and taste
Term
a nurse is evaluating discharge teaching that has been completed for a client
following total laryngectomy. which statement made by the client indicates that
the client does not accept or understand the teaching
i will be sure to carry an extra supply of facial tissue with me
i probably will not be able to go swimming
i will schedule an appointment for closure of my tracheostomy
i will check the batteries on our smoke detectors
Definition
i will schedule an appointment for closure of my tracheostomy
Term
a client with a large facial tumor is scheduled for a radical neck dissection. a nurse
in the preoperative best help the client considering the potential for an alteration
in body image from the procedure
show multiple photographs of clients who have had similar procedures
closely assess and monitor the client's verbal and nonverbal communication
direct the client's significant other to allow for the client's complete dependence
on him or her
remind the client that it is what is on the inside that counts
Definition
closely assess and monitor the client's verbal and nonverbal communication
Term
a 17 year old client with cystic fibrosis is visiting with a nurse in preparation for
leaving home for college. the nurse knows that the client needs further education
if the client states
i will bring extra cough medicine so as to not wake up my roommate at night
i will contact the college's health center and pass on my medical records
i will check to make sure they have good workout facilities
i will be really careful about washing my hands and staying away from sick friends
Definition
i will bring extra cough medicine so as to not wake up my roommate at night
Term
a public health nurse is planning a flu shot clinic. the nurse is working on
advertising. which groups should be the highest priority to target when advertising
the flu shot clinic. select all that apply
pregnant women
grade school children
nursing assistants at a nursing home
a hypertension clinic population
outpatient psychiatric population
spinal cord-injured population at an assisted living facility
Definition
pregnant women
nursing assistants at a nursing home
spinal cord-injured population at an assisted living facility
Term
a nurse is working at a telephone health service. which advice should the nurse
give to a client who has had 3 days of symptoms that strongly suggest influenza
reutrn to work after another day of rest
rest and increase fluid intake to 3 liters of fluid per day
use over the counter antihistamines
make an appointment to get the flu shot
Definition
rest and increase fluid intake to 3 liters of fluid per day
Term
a client hospitalized for a severe case of pneumonia is asking a nurse why a
sputum sample is needed. the nurse should reply that the primary reason is to
complete the first of three samples to be collected
differentiate between pneumonia and atelectasis
encourage expectoration of secretions
help select the appropriate antibiotic
Definition
help select the appropriate antibiotic
Term
a nurse is preparing to admit a client with a confirmed case of tuberculosis. which
action is essential to infection control for this client
providing a positive pressure airflow room
wearing gown and gloves when handling the client's stool or urine
using a NIOSH approved N95 respirator mask for staff and visitors
keeping the client quarantined in the room until antibiotic therapy has been
initiated
Definition
using a NIOSH approved N95 respirator mask for staff and visitors
Term
a client requires IV vancomycin for antibiotic-resistant pneumonia. the order calls
for 500 mg to be administered and the medication is supplied in a 100 mL
piggyback that contains 5 mg per 1 mL to run over 1 hour. in order to administer
the correct dose, a nurse should set the infusion pump to run at a rate of ___ ml
per hour
Definition
100
Term
a nurse is planning care for a client with AIDS who has been hospitalized for
Pneumocystitis carinii infection . which nursing diagnosis shoul be the nurse's first
priority for this client
fatigue related to hypermetabolism
imbalanced nutrition more than body requirements related to hypometabolism
ineffective cooping related to HIV diagnosis
fluid volume excess related to oral and intravenous fluid intake
Definition
fatigue related to hypermetabolism
Term
a client presents to an emergency department following a motorcycle crash. a
nurse assesses the client and notes uncoordinated or paradoxical chest rise and
fall as well as multiple bruises across the chest and torso, crepitus and tachypnea.
based on this assessment the nurse should
assist the placement of a cervical collar
anticipate the need to intubate the client
provide chest compressions
tape the chest wall
Definition
anticipate the need to intubate the client
Term
a nurse who is caring for a client in an emergency department who has five
fractured ribs from blunt chest trauma. the client is rating pain at 9 out of 10. for
which pain managemnt modality should the nurse advocate
nsaids
oral analgesics
regional/local analgesia (epidural or intercostal injection)
IV bolus meperidine (Demerol)
Definition
regional/local analgesia (epidural or intercostal injection)
Term
following an unrestrained motor vehicle crash a client presents to an emergency
department with multiple injuries including chest trauma. a physician notifies the
care team that the client has progressed to ARDS and requests that the family be
updated on the client's condition. the nurse should plan to discuss with the family
that
the condition generally stabilizes with positive prognosis
the client can be discharged with home oxygen
the condition is always fatal
the condition is highly life-threatening and that end-of-life concerns should be
addressed
Definition
the condition is highly life-threatening and that end-of-life concerns should be
addressed
Term
a nurse is caring for a client with a left sided chest tube attached to a wet suction
chest tube system. which obseration by the nurse would require immediate
intervention
bubbling in the suction chamber
dependent loop hanging off the edge of the bed
banded connections between tubing sections
occlusive dressing over chest tube insertion site
Definition
dependent loop hanging off the edge of the bed
Term
a nurse checks on a client following lower lobectomy for lung cancer. the nurse
finds that the client is dyspneic with respirations in the 40s, is hypotensive, has a
SaO2 at 86% on 10L close-fitting oxygen mask, has a trachea that is deviated
slightly to the left, and notes that the right side of chest is not expanding. which
action should be taken first
notify the physician
give the client whatever medication was ordered to decrease anxiety
check the chest tube to make sure it is not obstructed
turn up the oxygen liter flow
Definition
check the chest tube to make sure it is not obstructed
Term
a nurse is completing the health history for a client who has been taking
echinacea for a head cold. the client asks "why isn't this helping me feel better"
which of the following responses by the nurse would be the most accurate
there is limited information as to the effectiveness of herbal products
antibiotics are the agents needed to treat a head cold
the head cold should be gone within the month
combining herbal products with prescription antiviral medications is sure to help
you
Definition
there is limited information as to the effectiveness of herbal products
Term
A nurse is teaching a client about taking antihistamines. which of the following
instructions should the nurse include in the teaching plan. select all that apply
operating machinery and driving may be dangerous while taking antihistamines
continue taking antihistamines even if nasal infection develops
the effect of antihistamines is not felt until a day later
do not use alcohol with antihistamines
increase fluid intake to 2000 ml/day
Definition
operating machinery and driving may be dangerous while taking antihistamines
do not use alcohol with antihistamines
increase fluid intake to 2000 ml/day
Term
a client with allergic rhinitis is instructed on the corrct technique for using an
intranasal inhaler. which of the following statements would demonstrate to the
nurse that the client understands the instructions
i should limit the use of the inhaler to only morning and bedtime use
it is important to not shake the canister because that can damage the spray
device
i should hold one nostril closed while i insert the spray into the other nostril
the inhaler tip is inserted into the nostril and pointed toward the inside nostril wall
Definition
i should hold one nostril closed while i insert the spray into the other nostril
Term
which of the following would be an expected outcome for a client recovering
from an upper respiatory tract infection. the client will
maintain a fluid intake of 800 ml every 24 hours
experience chills only once a day
cough productively without chest discomfort
experience less nasal obstruction and discharge
Definition
experience less nasal obstruction and discharge
Term
the nurse teaches the client how to instill nose drops. which of the following
techniques is correct
the client uses sterile technique when handling the dropper
the client blows the nose gently before instilling drops
the client uses a new dropper for each instillation
the client sits in a semi folwer's position with the head tilted forward after
administration of the drops
Definition
the client blows the nose gently before instilling drops
Term
the nurse should include which of the following instructions in the teaching plan
for a client with chronic sinusitis
avoid the use of caffeinated beverages
perform postural drainage every day
take hot showers twice daily
report a temperature of 102 F or higher
Definition
take hot showers twice daily
Term
a client with allergic rhinitis asks the nurse what to do to decrease the rhinorrhea.
which of the following instructions would be appropriate for the nurse to give the
client
user your nasal decongesant spray regularly to help clear your nasal passages
ask the doctor for antibiotics. antibiotics wil help decrease the secretion
it is important to increase your activity. a daily brisk walk will help promote
drainage
keep a diary of when your symptoms occur. this can help you identify what
precipitates your attacks
Definition
keep a diary of when your symptoms occur. this can help you identify what
precipitates your attacks
Term
pseudoephedrine (Sudafed) has been prescribed as a nasal decongestant.
which of the following is a possible adverse effect of this drug
constipation
bradycardia
diplopia
restlessness
Definition
restlessness
Term
a health care provider has just inserted nasal packing for a client with epistaxis.
the client is taking ramipril (Altace) for hypertension. what should the nurse instruct
the client to do
use 81 mg of aspirin daily for relief of discomfort
omit the next dose of ramipril (Altace)
remove the packing if there is difficulty swallowing
avoid rigorous aerobic exercise
Definition
avoid vigorous aerobic exercise
Term
a client has had surgery for a deviated nasal septum. which of the following would
indicate that bleeding was occurring even if the nasal drip pad remained dry and
intact
nausea
repeated swallowing
increased respiratory rate
increased pulse
Definition
repeated swallowing
Term
a client who has undergone outpatient nasal surgery is ready for discharge and
has nasal packing in place. which of the following discharge instructions would
be appropriate for the client
avoid activities that elicit the valsalva maneuver
take aspirin to control nasal discomfort
avoid brushing the teeth until the nasal packing is removed
apply heat to the nasal area to control swelling
Definition
avoid activities that elicit the valsalva maneuver
Term
which of the following statements should indicate to the nurse that a client has
understood the discharge instructions provided after nasal surgery
i should no tshower until my packing is removed
i will take stool softeners and modify my diet to prevent constipation
coughing every 2 hours is important to prevent repiratory complications
it is importatn to blow my nose each day to remove the dried secretions
Definition
i will take stool softeners and modify my diet to prevent constipation
Term
the nurse is planning to give preoperative instructions to a client who will be
undergoing rhinoplasty. which of the following instructions should be included
after surgery, nasal packing will be in place for 7 to 10 days
normal saline nose drops will need to be administered preoperatively
the results of the surgery will be immediately obvious postoperatively
aspirin containing medications should not be taken for 2 weeks before surgery
Definition
aspirin containing medications should not be taken for 2 weeks before surgery
Term
which of the following assessments is a priority immediately after nasal surgery
assessing the client's pain
inspecting for periorbital ecchymosis
assessing respiratory status
measuring intake and output
Definition
assessing respiratory status
Term
after nasal surgery the client expresses concern about how to decrease facial
pain and swelling while recovering at home. which of the following discaharge
instruction would be most effective for decreasing pain and edema
take analgesics every 4 hours around the clock
use corticosteroid nasal spray as needed to control symptoms
use a bedside humidifier while sleeping
apply cold compresses to the area
Definition
apply cold compresses to the area
Term
a client is being discharged with nasal packing in place. the nurse should isntruct
the client to
perform frequent mouth care
use normal sline nose drops daily
sneeze and cough with mouth closed
gargle every 4 hours with salt water
Definition
perform frequent mouth care
Term
which of the following activities should the nurse teach the client to implement
after the removal of nasal packing on the 2nd postoperative day
avoid cleaning the nares until swelling has subsided
apply water soluble jelly to lubricate the nares
keep a nasal drip pad in place to absorb secretions
use a bulb syringe to gently irrigate nares
Definition
apply water soluble jelly to lubricate the nares
Term
the nurse is teaching a client how to manage a nosebleed. which of the folowing
instruction would be appropriate to give the client
tilt your head backward and pinch your nose
lie down flat and place an ice compress over the bridge of the nose
blow your nose getly with your neck flexed
sit down, lean forward, and pinch the soft portion of your nose
Definition
sit down, lean forward, and pinch the soft portion of your nose
Term
an elderly client had posterior packing inserted to control a severe nosebleed.
after insertion of the packing the client should be closely monitored for which of
the following compications
vertigo
bell's palsy
hypoventilation
loss of gag reflex
Definition
hypoventilation
Term
postoperative nursing management of the client following a radical neck
dissection for laryngeal cancer requires
complete bed rest minimizing head movement
vital signs once a shift
clear liquid diet started at 48 hours
frequent suctioning of the laryngectomy tube
Definition
frequent suctioning of the laryngectomy tube
Term
a client who has had a total laryngectomy appears withdrawn and depressed.
the client keeps the curtain drawn, refuses visitors, and indicates a desire to be
left alone. which nursing intervention would most likely be therapeutic for the
client
discussing the behavior with the spouse to determine the cause
exploring future plans
respecting the need for privacy
encouraging expression of feelings nonverbally and in writing
Definition
encouraging expression of feelings nonverbally and in writing
Term
the nurse is suctioning a client who had a laryngectomy. what is the maximum
amount of time the nurse should suction the client
10 sec
15 sec
25 sec
30 sec
Definition
10 sec
Term
when suctioning a tracheostomy tube 3 days following insertion the nurse should
follow which of the following procedures
use a sterile catheter each time the client is suctioned
clean the catheter in sterile water after each use and reuse for no longer than 8
hours
protect the catheter in sterile packaging between suctioning episodes
use a clean catheter with each suctioning and disinfect it in hydrogen peroxide
between uses
Definition
use a sterile catheter each time the client is suctioned
Term
the client with a laryngectomy does not want his family to see him. He indicates
that he thinks the opening in his throat is disgusting. the nurse should
initiate teaching about the care of a stoma
explain that the stoma will not always look as it does now
inform the client of the benefits of family support at this time
explore why the client believes the stoma is disgusting
Definition
explore why the client believes the stoma is disgusting
Term
the nurse is making rounds and ovserves the client who had a tracheostomy tube
inserted 2 days ago. the nursing policy manual recommends use of the gauze
pad. the nurse should
make sure the gauze pad is dry and the client is in a comfortable position
ask the nursing assistant to tie the trachostomy tube ties in the back of the client's
neck
reposition the gauze pad around the stoma with the open end downward
ask a registered nurse to change the ties and position another gauze pad around
the stoma
Definition
make sure the gauze pad is dry and the client is in a comfortable position
Term
what areas of education should the nurse provide employees in a factory making
products that cause respiratory irritation to reduce the risk of laryngeal cancer.
select all that apply
stopping smoking
using a HEPA filter in the home
limiting alcohol intake
brushing teeth after every meal
avoid raising the voice to be heard over the noise in the factory
Definition
stopping smoking
limiting alcohol intake
Term
a client has had hoarseness for more than 2 weeks. the nurse should
refer the client to a health care provider for a prescription for an antibiotic
instruct the client to gargle with salt water at home
assess the client for dysphagia
instrut the client to take a throat analgesic
Definition
assess the client for dysphagia
Term
a client has just returned from the postanesthesia care unit after undergoing a
laryngectomy. which of the following interventions should the nurse include in the
plan of care
maintain the head of the bed at 30 to 40 degrees
tach the client how to use esophageal speech
initiate small feedings of soft foods
irrigate drainage tubes as needed
Definition
maintain the head of the bed at 30 to 40 degrees
Term
which of the following is an expected outcomes or a client recovering from a total
laryngectomy. the client will
regain the ability to taste and smell food
demonstrate appropriate care of the gastrostomy tube
communicate feelings about body image changes
demonstrate sterile suctioning technique for stoma care
Definition
communicate feelings about body image changes
Term
which of the following home care instructions would be appropriate for a client
with a laryngectomy
perform mouth care every morning and evening
provide adequate humidity in the home
maintain a soft bland diet
limit physical activity to shoulder and neck exercises
Definition
provide adequate humidity in the home
Term
an elderly client with pneumonia and dementia has attempted several times to
pull out the IV and foley catheter. the nurse obtains a prescription for bilateral soft
wrist restraints. which nursing action is most appropriate
perform circulation checks to bilateral upper extremities each shift
attach the ties of the restraints to the bed frame
reevaluate the need for restraints and document weekly
ensure the restraint order has been signed by the physician within 72 hours
Definition
attach the ties of the restraints to the bed frame
Term
a 79 year old client is admitted to the hospital with a diagnosis of bacterial
pneumonia. while obtaining the client's health history, the nurse learns that the
client has osteoarthritis, follows a vegetarian diet, and is very concerned with
cleanliness. which of the following would most likely be a predisposing factor for
the diagnosis of pneumonia
age
osteoarthritis
vegetarian diet
daily bathing
Definition
age
Term
which of the following are significant data to gather form a client who has been
diagnosed with pneumonia. select all that apply
quality of breath sounds
presence of bowel sounds
occurence of chest pain
amount of peripheral edema
color of nail beds
Definition
quality of breath sounds
occurence of chest pain
color of nail beds
Term
A client with bacterial pneumonia is to be started on iv antibiotics. which of the
following diagnostic test must be completed before antibiotic therapy begins
urinalysis
sputum culture
chest radiograph
red blood cell count
Definition
sputum culture
Term
when caring for the client who is receiving an aminoglycoside antibiotic the nurse
shold monitor which of the following values
serum sodium
serum potassium
serum creatinine
serum calcium
Definition
serum creatinine
Term
penicillin has been prescribed for a client admitted to the hospital for treatment
of pneumonia. prior to administering the first dose of penicillin the nurse should
ask the client
do you have a history of seizures
do you have any cardiac history
have you had any recent infections
have you had a previous allergy to penicillin
Definition
have you had a previous allergy to penicillin
Term
a client with pneumonia has a temperature of 102.6 is diaphoretic and has a
productive cough. the nurse should include which of the following measures in
the plan of care
position changes every 4 hours
nasotracheal suctioning to clear secretions
frequent linen changes
frequent offering of a bedpan
Definition
frequent linen changes
Term
bed rest is prescribed for a client with pneumonia during the acute phase of the
illness. the nurse should determine the effectiveness of bedrest by assessing the
client's
decreased cellular demand for oxygen
reduced episodes of coughing
diminished pain when breathing deeply
ability to expectorate secretions more easily
Definition
decreased cellular demand for oxygen
Term
the cyanosis that accompanies bacterial pneumonia is primarily caused by which
of the following
decreased cardiac output
pleural effusion
inadequate peripheral circulation
decreased oxygenation of the blood
Definition
decreased oxygenation of the blood
Term
a client with pneumonia is experiencing pleuritic chest pain. the nurse should
assess the client for
a mild but constant aching in the chest
severe midsternal pain
moderate pain that worsens on inspiration
muscle spasm pain that accompanies coughing
Definition
moderate pain that worsens on inspiration
Term
which of the following measures would most likely be successful in reducing
pleuritic chest pain in a client with pneumonia
encourage the client to breathe shallowly
have the client practice abdominal breathing
offer the client incentive spirometry
teach the client to splint the rib cage when coughing
Definition
teach the client to splint the rib cage when coughing
Term
the nurse administers two 325 mg aspirin every 4 hours to a client with pneumonia.
the nurse should evaluate the outcome of administering the drug by assessing
which of the following. select all that apply
decreased pain when breathing
prolonged clotting time
decreased temperature
decreased respiratory rate
increased ability to expectorate secretions
Definition
decreased pain when breathing
decreased temperature
Term
which of the following mental status changes may occur when a client with
pneumonia is first experiencing hypoxia
coma
apathy
irritability
depression
Definition
irritability
Term
the client with pneumonia develops mild constipation and the nurse administers
docusate sodium (Colace) as prescribed. this drug works by
softening the stool
lubricating the stool
increasing stool bulk
stimulating peristalsis
Definition
softening the stool
Term
which of the following is an expected outcome for an elderly client following
treatment for bacterial pneumonia
a respiratory rate of 25 to 30 bpm
the ability to perform activities of daily living without dyspnea
a maximum loss of 5 to 10 lb of body weight
chest pain that is minimized by splinting the rib cage
Definition
the ability to perform activities of daily living without dyspnea
Term
a client newly diagnosed with tuberculosis is being admitted with the prescription
for isolation precautions for tuberculosis. the nurse should assign the client to
which type of room
a room at the end of the hall for privacy
a private room to implement contact precautions
a room near the nurses' station to ensure confidentiality
the implementation of contact precaustions for possible TB requires a private
room assignment
Definition
a room at the end of the hall for privacy
Term
which of the following symptoms is common in clients with active tuberculosis
weight loss
increased appetite
dyspnea on exertion
mental status changes
Definition
weight loss
Term
the client is receiving streptomycin in the treatment regimen of tuberculosis. the
nurse should assess for
decreased serum creatinine
difficulty swallowing
hearing loss
iv infiltration
Definition
hearing loss
Term
a client is receiving streptomycin for the treatment of tuberculosis. the nurse
should assess the client for eight cranial nerve damage by observing the client for
vertigo
facial paralysis
impaired vision
difficulty swallowing
Definition
vertigo
Term
the nurse should teach clients that the most common route of trasmitting tubercle
bacilli from person to person is through contaminated
dust particles
droplet nuclei
water
eating utensils
Definition
droplet nuclei
Term
what is the rationale that supports multidrug treatment for clients with tuberculosis
multiple drugs potentiate the drugs' actions
multiple drugs reduce undesirable drug adverse effects
multiple drugs allow reduced drug dosages to be given
multiple drugs reduce development of resistant strains of the bacteria
Definition
multiple drugs reduce development of resistant strains of the bacteria
Term
the client with tuberculosis is to be discharged home with community health
nursing follow-up. of the following nursing interventions, which should have the
highest priority
offering the client emotional support
teaching the client about the disease and its treatment
coordinating various agency services
assessing the client's environment for sanitation
Definition
teaching the client about the disease and its treatment
Term
which of the following techniques for administering the Mantoux test is correct
hold the needle and syringe almost parallel to the client's skin
pinch the skin when inserting the needle
aspirate before injecting the medication
massage the site after injecting the medicaiton
Definition
hold the needle and syringe almost parallel to the client's skin
Term
which of the following family members exposed to tuberculosis whould be at
highest risk for contracting the disease
45 year old mother
17 year old daughter
8 year old son
76 year old grandmother
Definition
76 year old grandmother
Term
the nurse is teaching a client who has been diagnosed with tuberculosis how to
avoid spreading the disease to family members. which statems indicate that the
client has understood the nurse's instructions. select all that apply
i will need to dispose of my old clothing when i return home
i should always cover my mouth and nose when sneezing
it is important that i isolate myself from family when possible
i should use paper tissues to cough in and dispose of them promptly
i can use regular plates and utensils whenever I eat
Definition
i should always cover my mouth and nose when sneezing
i should use paper tissues to cough in and dispose of them promptly
i can use regular plates and utensils whenever I eat
Term
a client has a positive reaction to the mantoux test. the nurse interprets this
reaction to mean that the client has
active tuberculosis
had contact with mycobacterium tuberculosis
developed a resistance to the tubercle bacilli
developed passive immunity to tuberculosis
Definition
had contact with mycobacterium tuberculosis
Term
a client with tuberculosis is taking isoniazin. to help prevent development of
peripheral neuropathies the nurse should instruct the client to
adhere to a low cholesterol diet
supplement the diet with pyridoxine (vitamin B6)
get extra rest
avoid excessive sun exposure
Definition
supplement the diet with pyridoxine (vitamin B6)
Term
the nurse should caution sexually active female clients taking isoniazid that the
drug has which of the following effects
increases the risk of vaginal infection
has mutagenic effects on ova
decreases the effectiveness of hormonal contraceptives
inhibits ovulation
Definition
decreases the effectiveness of hormonal contraceptives
Term
clients who have had active tuberculosis are at risk for recurrence. which of the
following conditions increases that risk
cool and damp weather
active exercise and exertion
physical and emotional stress
rest and inactivity
Definition
physical and emotional stress
Term
in which areas of the united states is the incidence of tuberculosis highest
rural farming areas
inner city areas
areas where clean water standards are low
suburban areas with significant industrial pollution
Definition
inner city areas
Term
the nurse should include which of the following instructions when developing a
teaching plan for a client who is receiving isoniazid and rifampin for treatment of
tuberculosis
take the medication with antacids
double the dosage if a drug does is missed
increase intake of dairy products
limit alcohol intake
Definition
limit alcohol intake
Term
a client who has been diagnosed with tuberculosis has been placed on drug
therapy. the medication regimen includes rifampin. which of the following
instructions should the nurse include in the client's teaching plan related to the
potential adverse effects of rifampin. select all that apply
having eye examinations every 6 months
maintaining follow up monitoring of liver enzymes
decreasing protein intake in the diet
avoiding alcohol intake
the urine may have an orange color
Definition
maintaining follow up monitoring of liver enzymes
avoiding alcohol intake
the urine may have an orange color
Term
the nurse is providing follow up care to a client with tuberculosis who does not
regularly take the prescribed medication. which nursing action would be most
appropriate for this client
ask the clients spouse to supervise the daily administration of the medications
visit the client weekly to verify complaince with taking the medication
notify the physician of the client's noncompliance and request a different
prescription
remind the client that the tuberculosis can be fatal if not treated promptly
Definition
ask the clients spouse to supervise the daily administration of the medications
Term
On the first postoperative day following a right-sided thoracotomy, a nurse is
assiting a client with arm and shoulder exercises. the client reports pain with the
exercises and why they must be performed. the nurse should explain that the
exercises
promote respiratory function
increase blood flow back to the heart and venous system
improve muscle mass to compensate for muslce removed during the procedure
prevent stiffening and loss of function
Definition
prevent stiffening and loss of function
Term
following a thoracotomy to remove a lung tumor a nurse is preparing a client to
be discharged to home. which are appropriate teaching points for the client.
select all that apply
avoid lifting greater than 20 pounds
build up exercise endurance
continue to buid endurance even when dyspneic
expect return to normal activity level and strength within 1 month
make time for frequent rest periods with activity
Definition
avoid lifting greater than 20 pounds
build up exercise endurance
make time for frequent rest periods with activity
Term
a nurse is partnered with a PCA on a med-surg floor. the PCA provides information
about the clients for whom the PCA has been caring. based on the information
from the PCA which client should the nurse attend to first
the client with a pulmonary embolus who has not had a bowel movement in 2
days
the client who underwent a video thoracoscopy with oxygen saturation readings
from 88% to 90% on oxygen at 4 L/NC
the client who underwent a wedge resection of right lung and has a blood
pressure of 100/65 mm Hg
the client who has rib fractures and has not voided for 6 hours after the urinary
catheter was removed
Definition
the client who underwent a video thoracoscopy with oxygen saturation readings
from 88% to 90% on oxygen at 4 L/NC
Term
a nurse is caring for a client following an open thoracotomy for removal of a large
tumor. extensive blood loss during the procedure required fluid resuscitation of
the client. the client is cyanotic and in respiratory distress with pink, frothy sputum
coming from the mouth. the nurse should immediately
put the client in high fowler's position
give a 200 ml fluid bolus
activate the respiratory code system
have the client cough and deep breathe
Definition
activate the respiratory code system
Term
a nurse observes for early manifestation of ARDS in a client being treated for
smoke inhalation. which signs indicate the possible onset of ARDS in this client
cough with blood tinged sputum and respiratory alkalosis
decrease in both white and red blood cell counts
diaphoresis and low SaO2 unresponsive to increased oxygen administration
hypertension and elevated PaO2
Definition
diaphoresis and low SaO2 unresponsive to increased oxygen administration
Term
the nurse reviews an aterial blood gas report for a client with COPD the results are
pH 7.35, PCO2 65; PO2 70; HCO3 34
apply a 100% nonrebreather mask
assess the vital signs
reposition the client
prepare for intubation
Definition
assess the vital signs
Term
when developing a discharge plan to manage the care of a client with COPD
the nurse should advise the client to expect to
develop respiratory infections easily
maintain current status
require less supplemental oxygen
show permanent improvement
Definition
develop respiratory infections easily
Term
the client with COPD is taking theophylline. the nurse should instruct the client to
report which of the following signs of theophylline toxicity. select all that apply
nausea
vomiting
seizures
insomnia
vision changes
Definition
nausea
vomiting
seizures
insomnia
Term
which of the following indicates that the client with COPD who has been charged
to home understands the care plan
the client promises to do pursed lip breathing at home
the client states actions to reduce pain
the client will use oxygen via a nasal cannula at 5 L/min
the client agrees to call the physician if dyspnea on exertion increases
Definition
the client agrees to call the physician if dyspnea on exertion increases
Term
which of the following physical assessment findings are normal for a client with
advanced COPD
increased anteroposterior chest diameter
underdeveloped neck nuscles
collapsed neck veins
increased chest excursions with respiration
Definition
increased anteroposterior chest diameter
Term
when instructing clients on how to decrease the risk of COPD the nurse should
emphasize which of the following
participate regularly in aerobic exercises
maintain a high protein diet
avoid exposure to people with known respiratory infections
abstain from cigarette smoking
Definition
abstain from cigarette smoking
Term
which of the following is an expected outcome of pursed lip breathing for clients
with emphysema
to promote oxygen intake
to strengthen the diaphragm
to strengthen the intercostal muscles
to promote carbon dioxide elimination
Definition
to promote carbon dioxide elimination
Term
which of the following is a prioirty goal for the client with COPD
maintaining functional ability
minimizing chest pain
increasing carbon dioxide levels in the blood
treating infectious agents
Definition
maintaining functional ability
Term
a client's arterial blood gas values are as follows: pH 7.31, PaO2 80; Pa CO2 65;
HCO3 36. the nurse should assess the client for
cyanosis
flushed skin
irritability
anxiety
Definition
flushed skin
Term
when teaching a client with COPD to conserve energy the nurse should teach
the client to lift objects
while inhaling through an open mouth
while exhaing through pursed lips
after exhaling but before inhaling
while taking a deep breath and holding it
Definition
while exhaling through pursed lips
Term
the nurse teaches a client with COPD to assess for signs and symptoms of right
sided heart failure. which of the following signs and symptoms should be included
in the teaching plan
clubbing of the nail beds
hypertension
peripheral edema
increased appetite
Definition
peripheral edema
Term
the nurse assesses the respiratory status of a client who is experiencing an
exacerbation of COPD secondary to an upper respiratory tract infection. which
of the following findings would be expected. which of the following findings would
be expected
normal breath sounds
prolonged inspiration
normal chest movement
coarse crackles and rhonchi
Definition
coarse crackles and rhonchi
Term
A client with COPD is experiencing dyspnea and has a low PaO2 level. the nurse
plans to administer oxygen as prescribed. which of the following statements is
true concerning oxygen administration to a client with COPD
high oxygen concentrations will cause coughing and dyspnea
high oxygen concentrations may inhibit the hypoxic stimulus to breathe
increased oxygen use will caue the client to become dependent on the oxygen
adminisration of
bronchodilators
oxygen
is
contraindicated
in
clients
who
are
using
Definition
high oxygen concentrations may inhibit the hypoxic stimulus to breathe
Term
which of the following diets would be most appropriate for a client with chronic
COPD
low fat, low cholesterol diet
bland, soft diet
low sodium diet
high calorie, high protein diet
Definition
high calorie, high protein diet
Term
the nurse administers theophylline to a client. when evaluating the effectiveness
of this medication the nurse should assess the client for which of the following
suppression of the client's respiratory infection
decrease in bronchial secretions
less difficulty breathing
thinning of tenacious, purulent sputum
Definition
less difficulty breathing
Term
the nurse is planning to teach a client with COPD how to cough effectively. which
of the following instructions should be included
take a deep abdominal breath, bend forward and cough three or four times on
exhalation
lie flat on the back, splint the thorax, take two deep breaths, and cough
take several rapid, shallow breaths and then cough forcefully
assume a side-lying position, extend the arm over the head, and alternate deep
breathing with coughing
Definition
take a deep abdominal breath, bend forward and cough three or four times on
exhalation
Term
a client uses a metered dose inhaler (MDI) to aid in management of asthma.
which action indicates to the nurse that the client needs further instruction
regarding its use. select all that apply
activation of the MDI is not coordinated with inspiration
the client inspires rapidly when using the MDI
the client holds his breath for 3 seconds after inhaling with the MDI
the client shakes the MDI after use
the client performs puffs in rapid succession
Definition
activation of the MDI is not coordinated with inspiration
the client inspires rapidly when using the MDI
the client holds his breath for 3 seconds after inhaling with the MDI
the client shakes the MDI after use
the client performs puffs in rapid succession
Term
a 34 year old female with a history of asthma is admitted to the emergency
department. the nurse notes that the client is dyspneic, with a respiratory rate of
35 breaths/min, nasal flaring, and use of accessory muscles. auscultation of the
lung fields reveals greatly diminished breath sounds. based on these findings,
which action should the nurse take to initate care of the client
initiate oxygen therapy as prescribed and resasses the client in 10 minutes
draw blood for an arterial blood gas
encourage the client to relax and breathe slowly through the mouth
administer bronchodilators as prescribed
Definition
administer bronchodilators as prescribed
Term
a client experiencing a severe asthma attack has the following arterial blood gas
results: pH 7.33, PCO2 48, PO2 58; HCO3 26
albuterol (proventil) nebulizer
chest xray
ipratropium (atrovent) inhaler
sputum culture
Definition
albuterol (proventil) nebulizer
Term
a client with acute asthma is prescribed short-term corticosteroid therapy. which
is the expected outcome for the use of steroids in clients with asthma
promote bronchodilation
act as an expectorant
have an anti-inflammatory effect
prevent devleopment of respiratory infections
Definition
have an anti-inflammatory effect
Term
the nurse is teaching the client how to use a metered dose inhaler (MDI) to
administer a corticosteroid. which of the following indicates that the client is using
the MDI correctly. select all that apply
the inhaler is held upright
the head is tilted down while inhaling the medicine
the client waits 5 minutes between puffs
the client rinses the mouth with water following administration
the client lies supine for 15 minutes following administration
Definition
the inhaler is held upright
the client rinses the mouth with water following administration
Term
a client is prescribed metaproterenol (Alupent) via metered-dose inhaler, two
puffs every 4 hours. the nurse instructs the client to report adverse effects. which
of the following are potential adverse effects of metaproterenol
irregular heartbeat
constipation
pedal edema
decreased pulse rate
Definition
irregular heartbeat
Term
a client who has been taking flunisolide nasal spray (Nasalide) two inhalations a
day for treatment of asthma has painful, white paatches in the mouth. which
response by the nurse would be most appropriate
this is an aticipated adverse efect of your medication. it should go away in a
couple of weeks
you are using your ihaler too much an it has irritated your mouth
you have developed a fungal infection from your medication. it will need to be
treated with an antifungal agent
be sure to brush your teeth and floss daily. good oral hygiene will treat this problem
Definition
you have developed a fungal infection from your medication. it will need to be
treated with an antifungal agent
Term
which of the following is an expected outcome for an adult client with well
controlled asthma
chest xray demonstrates minimal hyperinflation
temperature remains lower than 100F
arterial blood gas analysis demonstrates a decrease in PaO2
breath sounds are clear
Definition
breath sounds are clear
Term
which of the following health promotion activities should the nurse include in the
discharge teaching plan for a client with asthma
incorporate physical exercise as tolerated into the daily routine
monitor peak flow numbers after meals and at bedtime
eliminate stressors in the work and home enviornment
use sedatives to ensure uninterrupted sleep at night
Definition
incorporate physical exercise as tolerated into the daily routine
Term
the nurse should teach the client with asthma that which of the following is one
of the most common precipitating factors of an acute asthma attack
occupational exposure to toxins
viral respiratory infections
exposure to cigarette smoke
exercising in cold temperatures
Definition
viral respiratory infections
Term
which of the following findings would most likely indicate the presence of a
respiratory infection in a client with asthma
cough productive of yellow sputum
bilateral expiratory wheezing
chest tightness
respiratory rate of 30 breaths/min
Definition
cough productive of yellow sputum
Term
the nurse is caring for a client who has asthma. the nurse should conduct a
focused assessment to detect which of the following
increased forced expiratory voume
normal breath sounds
inspiratory and expiratory wheezing
morning headaches
Definition
inspiratory and expiratory wheezing
Term
the nurse has assisted the physician at the bedside with insertion of a left
subclavian, triple lumen catheter in a client admitted with lung cancer. suddenly
the client becomes restless and tachypnic. the nurse should
assess breath sounds
remove the catheter
insert a peripheral iv
reposition the client
Definition
assess breath sounds
Term
a female client diagnosed with lung cancer is to have a left lower lobectomy.
which of the following increases the client's risk of developing postoperative
pulmonary complications
height is 5 feet, 7 inches and weight is 110 lb
the client tends to keep her real feelings to herself
she ambulates and can climb one flight of stairs without dyspnea
the client is 58 years of age
Definition
height is 5 feet, 7 inches and weight is 110 lb
Term
the nurse in the perioperative area is preparing a client for surgery and notices
that the client looks sad. the client says. "i'm scared of having cancer. it's so
horrible and i brought it on myself. i should have quit smoking years ago." what
would be the nurse's best response to the client
it's okay to be scared. what is it about cancer that you're afraid of
it's normal to be scared. i would be too. we'll help you through it
don't be so hard on yourself. you don't know if our smoking caused the cancer
do you feel guilty because you smoked
Definition
it's okay to be scared. what is it about cancer that you're afraid of
Term
a client who underwent a left lower lobectomy has been out of surgery for 48
hours. the client is receiving morphine sulfate via a PCA system and reports having
pain in the left thorax that worsens when coughing. the nurse should
let the client rest, so that the client is not stimulated to cough
encourage the client to take deep breaths to help control the pain
check that the PCA device is functioning properly then reassure the client that
the machine is working and will relieve the pain
obtain a more detailed assessment of the client's pain using a pain scale
Definition
obtain a more detailed assessment of the client's pain using a pain scale
Term
which of the following areas is a priority to evaluate when completing discharge
planning for a client who has had a lobectomy for treatment of lung cancer
the support available to assist the client at home
the distance the client lives from the hospital
the client's ability to do home blood pressure monitoring
the client's knowledge of the causes of lung cancer
Definition
the support available to assist the client at home
Term
which of the following would be a significant intervention to help prevent lung
cancer
encourage cigarette smoker to have yearly chest radiographs
instruct people about techniques for smoking cessation
recommend that people have their houses and apartments checked for asbestos
leakage
encourage people to install central air filters in their homes
Definition
instruct people about techniques for smoking cessation
Term
after a thoracotomy the nurse instructs the client to perform deep breathing
exercises. which of the following is an expected outcome of these exercises
deep breathing elevates the diaphragm which enlarges the thorax and increases
the lung surface available for gas exchange
deep breathing increases blood flow to the lungs to allow them to recover from
the trauma of surgery
deep breathing controls the rate of air flow to the remaining lobe so that it will not
become hyperinflated
deep breathing expands the alveoli and increases the lung surface available for
ventilation
Definition
deep breathing expands the alveoli and increases the lung surface available for
ventilation
Term
following thoracotomy the client has severe pain. which of the following strategies
for pain management will be most effective for this client
repositioning the client immediately after administering pain medication
reassessing the client 30 minutes after administering pain medication
verbally reassuring the client after administering pain medication
readjusting the pain medication dosage as needed according to the client's
condition
Definition
reassessing the client 30 minutes after administering pain medication
Term
while assessing a thoracotomy incision area from which a chest tube exits the
nurse feels a crackling sensation under the fingertips along the entire incision.
which of the following should be the nurse's first action
lower the head of the bed and call the physician
prepare an aspiration tray
mark the area with a skin pencil at the outer periphery of the crackling
turn off the suction of the chest drainage system
Definition
mark the area with a skin pencil at the outer periphery of the crackling
Term
when teaching a client to deep breathe effectively after a lobectomy the nurse
should instruct the client to do which of the following
contract the abdominal muscles, take a slow deep breath through the nose and
hold it for 3 to 5 seconds then exhale
contract the abdominal muscles, take a deep breath through the mouth, and
exhale slowly as if trying to blow out a candle
relax the abdominal muscles, take a deep breath through the nose, and hold it
for 3 to 5 seconds
relax the abdominal muscles, take a deep breath through the mouth and exhale
slowly over 10 seconds
Definition
contract the abdominal muscles, take a deep breath through the mouth, and
exhale slowly as if trying to blow out a candle
Term
which of the following rehabilitative measures should the nurse teach the client
who has undergone chest surgery to prevent shoulder ankylosis
turn from side to side
raise and lower the head
raise the arm on the affected side over the head
flex and extend the elbow on the affected side
Definition
raise the arm on the affected side over the head
Term
when caring for a client with a chest tube and water seal drainage system the
nurse should
verify that the air vent on the water seal drainage system is capped when the
suction is off
strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs
ensure that the chest tube is clamped when moving the client out of the bed
make sure that the drainage apparatus is always below the client's chest level
Definition
make sure that the drainage apparatus is always below the client's chest level
Term
A client has a chest tube attached to a water seal drainage system and the nurse
notes that the fluid in the chest tube and in the water seal column has stopped
fluctuating. the nurse should determine that
the lung has fully expanded
the lung has collapsed
the chest tube is in the pleural space
the mediastinal space has decreased
Definition
the lung has fully expanded
Term
the nurse observes a constant gentle bubbling in the water seal column of a water
seal chest drainage system. the nurse should
continue monitoring as usual; this is expected
check the connectors between the chest and drainage tubes and where the
drainage tube enters the collection bottle
decrease the suction to -15 mc H2O and continue observing the sytem for
changes in bubbling during the next several hours
drain half of the water from the water-seal chamber
Definition
check the connectors between the chest and drainage tubes and where the
drainage tube enters the collection bottle
Term
a client who underwent a lobectomy and has a water seal chest drainage system
is breathing with a little more effort and at a faster rate than 1 hour ago. the client's
pulse rate is also increased. the nurse should
check the tubing to ensure that the client is not lying on it or kinking it
increase the suction
lower the drainage bottles 2 to 3 feet below the level of the client's chest
ensure that the chest tube has two clamps on it to prevent leaks
Definition
check the tubing to ensure that the client is not lying on it or kinking it
Term
which of the following should be readily available at the bedside of a client with
a chest tube in place
a tracheostomy tray
another sterile chest tube
a bottle of sterile water
a spirometer
Definition
a bottle of sterile water
Term
the nurse is preparing to assist with the removal of a chest tube. which of the
following is appropriate at the site fro which the chest tube is removed
adhesive strip (steri-strips)
petroleum gauze
4 x 4 gauze with antibioitic ointment
no dressing is necessary
Definition
petroleum gauze
Term
a nurse shold interpret which of the following as an early sign of a tension
pneumothroax in a client with chest trauma
diministed bilateral breath sounds
muffled heart sounds
respiratory distress
tracheal deviation
Definition
respiratory distress
Term
a young adult is admitted to the emergency department after an automobile
accident .the client has severe pain in the right chest where there was an impact
on the steering wheel. which is the primary client goal at this time
reduce the client's anxiety
maintain adequate oxygenation
decrease chest pain
maintain adequate circulating volume
Definition
maintain adequate oxygenation
Term
a client with rib fractures and a pneumothorax has a chest tube inserted that is
connected to a water seal chest tube drainage system. the nurse notes that the
fluid in the water seal column is fluctuating with each breath that the client takes.
what is the significance of this fluctuation
an obstruction is present in the chest tube
the client is developing subcutaneous emphysema
the chest tube system is functioning properly
there is a leak in the chest tube system
Definition
the chest tube system is functioning properly
Term
a client who is recovering from chest trauma is to be discharged home with a
chest tube drainage system intact. the nurse should instruct the client to call the
physician for which of the folowing
respiratory rate greater than 16 breaths/min
continuous bubbling in the water-seal chamber
fluid in the chest tube
fluctuation of fluid in the water seal chamber
Definition
continuous bubbling in the water-seal chamber
Term
which of the following findings would suggest pneumothorax in a trauma victim
pronounced crackles
inspiratory wheezing
dullness on percussion
absent breath sounds
Definition
absent breath sounds
Term
for a client with rib fractures and a pneumothorax, the physician prescribes
morphine sufate 1 to 2 mg/h given IV as needed for pain. the nursing care goal is
to provide adequate pain control so that the client can breath effectively. which
of the following outcomes would indicate successful achievement of this goal
pain rating of 0/10 by the client
decreased client anxiety
respiratory rate of 26 breaths/min
PaO2 of 70 mg Hg
Definition
pain rating of 0/10 by the client
(I think this answer is stupid b/c I think it's not realistic to expect 0/10 pain for a rib
fracture, even with morphine)
Term
a client undergoes surgery to repair lung injuries. postoperative prescriptions
include the transfusion of one unit of packed red blood cells at a rate of 60 ml/hr.
how long will this transfusion take to infuse
2 hours
4 hours
6 hours
8 hours
Definition
4 hours
Term
the primary reason for infusing blood at a rate of 60 ml/h is to help prevent which
of the following complications
emboli formation
fluid volume overload
red blood cell hemolysis
allergic reation
Definition
fluid volume overload
Term
a client has been in an automobile accident and the nurse is assessing the client
for possible pneumothorax. the nurse should assess the client for
sudden sharp chest pain
wheezing breath sounds over affected side
hemoptysis
cyanosis
Definition
sudden sharp chest pain
Term
the physician has inserted a chest tube in a client with a pneumothorax. the nurse
should evaluate the effectiveness of the chest tube
for administration of oxygen
to promote formation of lung scar tissue
to insert antibiotics into the pleural space
to remove air and fluid
Definition
to remove air and fluid
Term
a client is undergoing a thoracentesis the nurse should monitor the client during
and immediately after the procedure for which of the following. select all that
apply
pneumothorax
subcutaneous emphysema
tension pneumothorax
pulmonary edema
infection
Definition
pneumothorax
subcutaneous emphysema
tension pneumothorax
pulmonary edema
Term
when assessing a client with chest trauma the nurse notes that the client is taking
small breaths at first then bigger breaths then a couple of small breaths then 10
to 20 seconds of no breaths. the nurse should chart the breathing pattern as
cheyne stokes respiration
hyperventilation
obstructive sleep apnea
bior's respiration
Definition
cheyne stokes respiration
Term
the nurse has placed the intubated client with ARDS in prone position for 30
minutes. which of the following would require the nurse to discontinue prone
positioning and return the client to the supine position. select all that apply
the family is coming in to visit
the client has increased secrtions requiring frequent suctioning
the SpO2 and PO2 have decreased
the client is tachycardic with drop in blood presssure
the face has increased skin breakdown and edema
Definition
the SpO2 and PO2 have decreased
the client is tachycardic with drop in blood presssure
the face has increased skin breakdown and edema
Term
the nurse has calculated a low PaO2/FIO2 ratio less than 150 for a client with
ARDS. the nurse should place the client in which position to improve oxygenation,
ventilation distribution, and drainage of secretions
supine
semi flowlers
lateral side
prone
Definition
prone
Term
a client with ARDS has fine crackles at lung bases and the respirations are shallow
at a rate of 28 breaths/min. the client is restless and anxious. in addition to
monitoring the arterial blood gas results, the nurse should do which of the
following. select all that apply
monitor serum creatine and BUN levels
administer a sedative
keep the head of the bed flat
administer humidified oxygen
auscultate the lungs
Definition
monitor serum creatine and BUN levels
administer humidified oxygen
auscultate the lungs
Term
which of the following interventions would be most likely to prevent the
development of ARDS
teaching cigarette smoking cessation
maintaining adequate serum potassium
monitoring clients for signs of hypercapnia
replacing fluids adequately during hypovolemic states
Definition
replacing fluids adequately during hypovolemic states
Term
the nurse interprets which of the following as an early sign of ARDS in a client at
risk
elevated carbon dioxide level
hypoxia not responsive to oxygen therapy
metabolic acidosis
severe, unexplained electrolyte imbalance
Definition
hypoxia not responsive to oxygen therapy
Term
a client with ARDS is on a ventilator. the clients peak inspiratory pressures and
spontaneous respiratory rate are increasing and the PO2 is not improving. using
SBAR technique for communication, the nurse calls the physician with the
recommendation for
initiating iv sedation
starting high protein diet
providing pain medication
increasing the ventilator rate
Definition
initiating iv sedation
Term
a client diagnosed with acute pancreatitis 5 days ago is experiencing respiratory
distress. the nurse should report which of the following to the health care provider
arterial oxygen level of 46 mm Hg
respirations of 12
lack of adventitious lung sounds
oxygen saturation of 96% on room air
Definition
arterial oxygen level of 46 mm Hg
Term
a client has the following arterial blood gas values: pH 7.52, PaO2 50 mm Hg;
PaCO2 28 mm Hg; HCO3 24. based upon the client's PaO2 which of the following
conclusions would be accurate
the client is severely hypoxic
the oxygen level is low but poses no risk for the client
the client's PaO2 level is within normal range
the client requires oxygen therapy with very low oxygen concentrations
Definition
the client is severely hypoxic
Term
a client has the following arterial blood gas values: pH 7.52, PaO2 50 mm Hg;
PaCO2 28 mm Hg; HCO3 24.the nurse determines that which of the following is a
possible cause for these findings
COPD
diabetic ketoacidosis with Kussmaul's respirations
myocardial infarction
pulmonary embolus
Definition
pulmonary embolus
Term
which of the following interventions should the nurse anticipate in a client who
has been diagnosed with ARDS
tracheostomy
use of a nasal cannula
mechanical ventilation
insertion of a chest tube
Definition
mechanical ventilation
Term
which of the following conditions can place a client at risk for ARDS
septic shock
COPD
asthma
heart failure
Definition
septic shock
Term
which of the following assessments is most appropriate for determining the correct
placement of an endotracheal tube in a mechanically ventilated client
assessing the client's skin color
monitoring the respiratory rate
verifying the amount of cuff inflation
auscultating breath sounds bilaterally
Definition
auscultating breath sounds bilaterally
Term
which of the following nursing interventions would promote effective airway
clearance in a client with ARDS
administering oxygen every 2 hours
turning the client every 4 hours
administering sedatives to promote rest
suctioning if cough is ineffective
Definition
suctioning if cough is ineffective
Term
which of the following complication is associated with mechanical ventilation
gastrointestinal hemmorhage
immunosuppression
increased cardiac output
pulmonary emboli
Definition
gastrointestinal hemmorhage
Term
a client is admitted to the emergency department with a headache, weakness,
and slight confusion. the physician diagnoses carbon monoxide poisoning. what
should the nurse do first
initiate gastric lavage
maintain body temperature
administer 100% oxygen by mask
obtain a psychiatric referral
Definition
administer 100% oxygen by mask
Term
a confused client with carbon monoxide poisoning experiences dizziness when
ambulating to the bathroom. the nurse should
put all four side rails up on the bed
ask the CNA to place restraints on the client's upper extremities
request that the client's roomate put the call light on when the client is attempting
to get out of bed
check on the client at regular intervals to ascertain the need to use the bathroom
Definition
check on the client at regular intervals to ascertain the need to use the bathroom
Term
which of the following is an expected outcome for a client with carbon dioxide
poisoning
a relatively matched v/q ratio
a low v/q ratio
a high v/q ratio
an equal PaO2 and PaCO2 ratio
Definition
a relatively matched v/q ratio
Term
the nurse should place a client being admitted to the hospital with suspected
tuberculosis on what type of isolation
standard precautions
contact precautions
droplet precautions
airborne precautions
Definition
airborne precautions
Term
a client has developed a hospital acquired pneumonia. when preparing to
administer cephalexin (Keflex) 500 mg, the nurse notices that the pharmacy sent
cefazolin (Kefzol). what should the nurse do. select all that apply
administer the cefazolin (Kefzol)
verify the medication prescription as written by the physician
contact the pharmacy and speak to a pharmacist
request that cephalexin (Keflex) be sent promptly
return the cefazolin (Kefzol) to the pharmacy
Definition
verify the medication prescription as written by the physician
contact the pharmacy and speak to a pharmacist
request that cephalexin (Keflex) be sent promptly
return the cefazolin (Kefzol) to the pharmacy
Term
which of the following individuals has the highest priority for receiving seasonal
influenza vaccination
a 60 year old man with a hiatal hernia
a 36 year old woman with 3 children
a 50 year old woman caring for a spouse with cancer
a 60 year old woman with osteoarthritis
Definition
a 50 year old woman caring for a spouse with cancer
Term
the nurse is a member of a team that is planning a client centered approach to
care of clients with COPD using the chronic care model. the teach should focus
on improving quality of care and delivery in which of the following areas. welect
all that apply
the community
clinical information systems
devliery system design
administrative leadership
emphasis on the acute care setting
Definition
the community
clinical information systems
devliery system design
(no idea what "chronic care model" is, lol)
Term
the nurse is caring for a client who has been placed on droplet precautions. which
of the following protective gear is required to take care of this client. select all
that apply
gloves
gown
surgical mask
glasses
respirator
Definition
gloves
gown
surgical mask
glasses
(lippincott says glasses for droplet)
Term
while making rounds, the nurse finds a client with COPD sitting in a wheelchair
slumpted over a lunch tray. after determining the client is unresponsive and
calling for help, the nurse's first action should be to
push the code blue button
call the rapid response team
open the client's airway
call for a defibrillator
Definition
open the client's airway
Term
a nurse performs an ABG sampling at 0930 on a client who has a heparin drip
infusing. at which of the following times will it be appropriate for the nurse to
discontinue holding pressure on the puncture site
0935
0940
0945
0950
Definition
0950
Term
which of the following can cause a low pulse ox reading. select all that apply
nail polish
inadequate peripheral circulation
hyperthermia
increased hgb level
edema
Definition
nail polish
inadequate peripheral circulation
edema
Term
a nurse is caring for a client following a bronchoscopy. which of the following clien
findings should the nurse report to the primary care provider?
blood tinged sputum
dry, non productive cough
sore throat
bronchospasms
Definition
bronchospasms
Term
a nurse is caring for a client who is scheduled for a thoracentesis at the bedsie.
which of the following items should the nurse ensure is in the client's room . select
all that apply
oxygen equpiment
incentive spirometer
pulse oximeter
thoracentesis tray
suture removal kit
Definition
oxygen equpiment
pulse oximeter
thoracentesis tray
Term
which of the following are causes for concern following a throacentesis. select all
that apply
dyspnea
localized bloody drainage contained on the dressing
fever
hypotension
SaO2 of 95%
soreness around puncture site
Definition
dyspnea
fever
hypotension
Term
which of the following items should the nurse have placed in the client with a
chest tube's room select all that apply
oxygen
sterile water
enclosed hemostat clamps
indwelling urinary catheter
occlusive dressing
suction source
bladder scan machine
Definition
oxygen
sterile water
enclosed hemostat clamps
occlusive dressing
suction source
Term
while assessing the client the nurse notices that the client's chest tube has
become dislodged. which of the following actions should the nurse take first
place the tubing into sterile water to restore the water seal
apply sterile gauze to the site
tape or clamp all connections
assess the client's respiratory status
Definition
apply sterile gauze to the site
Term
a nurse is assessing the functioning of a client's chest drainage system. which of
the following are expected client findings. select all that apply
continuous bubbling in the water seal chamber
gentle constant bubbling in the suction control chamber
rise and fall in the level of water in the water seal chamber with inspiration and
expiration
exposed sutures without dressing
drainage system is upright at chest level
Definition
gentle constant bubbling in the suction control chamber
rise and fall in the level of water in the water seal chamber with inspiration and
expiration
Term
a nurse is assisting a provider with the removal of a chest tube. which of the
following should the nurse instruct the client to do
lie on his left side during removal
hold his breath
inhale deeply during removal
perform the valsalva maneuver during removal
Definition
perform the valsalva maneuver during removal
Term
which of the following are indications that a nurse should suction a client. select
all that apply
spontaneous cough
cyanosis
SaO2 greater than 95%
tachypnea
visualization of secretions
Definition
cyanosis
tachypnea
visualization of secretions
Term
a nurse is caring for a client who has secretions in the airway. which of the
following is the most effective method for clearing the secretions
endotracheal suction
oropharyngeal suction
deep breathing and coughing
nasopharyngeal suction
Definition
deep breathing and coughing
Term
a nurse should measure a clients airway depth for nasopharyngeal and
nasogtracheal suctioning by
determining the distance from the nares to the sternum
determining the distance from the corner of the mouth to the earlobe
determining the distance from the tip of the nose to the earlobe
inserting the catheter until resistance is met
Definition
determining the distance from the tip of the nose to the earlobe
Term
a nurse is caring for a client who has a tracheotomy. which of the following
interventions should the nurse include. select all that apply
use medical aseptic technique when performing tracheostomy care
change the tracheostomy ties each time tracheostomy care is given
provide the client with materials for nonverbal communication
keep pressure greater than 30 mm Hg
clean the stoma site with half-strength hydrogen peroxide followed by 0.9%
sodium chloride
Definition
provide the client with materials for nonverbal communication
clean the stoma site with half-strength hydrogen peroxide followed by 0.9%
sodium chloride
(these answers don't seem right at all to me)
Term
the nurse prepares to perfrom endotracheal suctioning. which of the following
are appropriate guidelines. select all that apply
set wall suction at 150 mm Hg to ensure adequate suction
apply intermittent suction while inserting and withdrawing the catheter
provide hyperoxygenation to the client with 100% FiO2 before suctioning
clear the catheter and tubing and save for later use
maintain surgical aseptic technique
Definition
provide hyperoxygenation to the client with 100% FiO2 before suctioning
maintain surgical aseptic technique
Term
delivers an FiO2 of 24% to 55% at flow rates of 2 to 10 L/min via different sized
adaptors
nasal cannula
simple face mask
nonrebreather mask
venturi mask
face tent
Definition
venturi mask
Term
delivers an FiO2 of 24% to 100% at flow rates of at least 10 L/min and provides high
humidification of oxygen
nasal cannula
simple face mask
nonrebreather mask
venturi mask
face tent
Definition
face tent
Term
delivers an FiO2 of 24% to 55% to 44% at a flow rate of 1 to 6L/min via tubing with
two small prongs for insertion into the nares
nasal cannula
simple face mask
nonrebreather mask
venturi mask
face tent
Definition
nasal cannula
Term
delivers an FiO2 of 40% to 60% at flow rates of 5 to 8 L/min for short term oxygen
therapy
nasal cannula
simple face mask
nonrebreather mask
venturi mask
face tent
Definition
simple face mask
Term
delivers an FiO2 of 80% to 95% at flow rates of 10 to 15 L/min to keep the reservoir
bag 2/3 full during inspiration and expiration
nasal cannula
simple face mask
nonrebreather mask
venturi mask
face tent
Definition
nonrebreather mask
Term
late or early sign of hypoxia: confusion and stupor
Definition
late
Term
late or early sign of hypoxia: pale skin and mucous membranes
Definition
early
Term
late or early sign of hypoxia: bradycardia
Definition
late
Term
late or early sign of hypoxia: hypotension
Definition
late
Term
late or early sign of hypoxia:elevated blood pressure
Definition
early
Term
late or early sign of hypoxia: restlessness
Definition
early
Term
late or early sign of hypoxia: cyanotic skin and mucous membranes
Definition
late
Term
a nurse is caring for a client who has dyspnea. in which of the following postions
should the nurse place the client
supine
dorsal recumbent
fowler's
lateral
Definition
fowler's
Term
which of the following oxygen delivery devices is used when a prcise amount of
oxygen must be delivered
nonrebreather mask
ventrui mask
nasal cannula
simple face mask
Definition
venturi mask
Term
which of the following modes of ventilation can increase conditioning of the
respiratory muscles. select all that apply
assist-control
syncrhonized intermittent mandatory ventilation
continuous positive airway pressure
pressure support ventilation
independent lung ventilation
Definition
syncrhonized intermittent mandatory ventilation
continuous positive airway pressure
pressure support ventilation
Term
a nurse is training a newly licensed nurse who is caring for a client who is receiving
mechanical ventilation. the ventilator has been placed on presure support
ventilation PSV mode. the newly licensed nurse demonstrates an understanding
of PSV by stating that pressure support maintains the amount of pressure
in the lungs to open alveoli and prevent ateectasis
on spontaneous ventilation to decrease the work of breathing
on spontaneous ventilation to increase the work of breathing
on continuous ventilation to decrease the work of breathing
Definition
on spontaneous ventilation to decrease the work of breathing
Term
a nurse is orienting a newly licensed nurse on how to complete a routine
assessment for a client who is receiving mechanical ventilaton. which of the
following should be included in the newly licensed nurse's assessment of the client
assess blood pressure every 6 to 8 hr
assess blood pressure every 2 to 4 hr
assess breath sounds every 6 to 8 hr
assess breath sounds every 2 to 4 hr
Definition
assess breath sounds every 2 to 4 hr
Term
which of the following parameters indicate deterioration in the client's respiratory
status. select all that apply
SaO2 95%
wheezing
retraction of sternal muscles
warm and pink extremities and mucous membranes
premature ventricular complexes
respiratory rate of 34/min
anxiety
Definition
wheezing
retraction of sternal muscles
premature ventricular complexes
respiratory rate of 34/min
anxiety
Term
two hours after arriving on the medical-surgical unit, the client develops dyspnea.
SaO2 is 91%, and the client is exhibiting audible wheezing and use of accessory
muscles. which of the following medications should the nurse expect to administer
antibiotic
beta-blocker
antiviral
beta2 agonist
Definition
beta2 agonist
Term
a nurse is completing discharge teaching with a client who has a new prescription
for prednisone for asthma. which of the following client statements indicates a
need for further teaching
i will drink plenty of fluids while taking this medication
i will tell the doctor if i have black, tarry stools
i will take my medication on an empty stomach
i will monitor my mouth for cold sores
Definition
i will take my medication on an empty stomach
Term
when discharging a client home who is on oxygen, which of the following is most
important for the nurse to teach
smoking cessation
equipment maintenance
incorporating rest into ADLs
anger management
Definition
smoking cessation
Term
a nurse is caing for a client who has COPD. upon discharge the client is
concerned that he will never be able to leave his house now that he has been
placed on continuous oxygen. which of the following statements should the nurse
make
there are portable oxygen delivery systems that you can take with you
when you go out you can remove the oxygen and then reapply it when you
get home
you probably will not be able to go out as much as you used to
home health services will come to you so you will not need to get out
Definition
there are portable oxygen delivery systems that you can take with you
Term
which of the following clients have an increased risk for developing pneumonia.
select all that apply
client who has dysphagia
client who has AIDS
client who was vaccinated for pneumoococcus and influenza 6 months ago
client who is post operative and has received local anesthesia
client who has a closed head injury and is receiving ventilation
client who has myasthenia gravis
Definition
client who has dysphagia
client who has AIDS
client who has a closed head injury and is receiving ventilation
client who has myasthenia gravis
Term
a nurse is caring for a 76 year old female client brought in to a clinic by her
husband. the husband states that his wife woke up this morning and did not
recognnize him or know where she was. the client reports chills and chest pain
that worsens with inspiration. which of the following is the highet priority nursing
task
obtain baseline vital signs and oxygen saturation
obtain a sputum culture
obtain a complete history from the client
provide a pneumococcal vaccination
Definition
obtain baseline vital signs and oxygen saturation
Term
a nurse is caring for a client who has pneumonia and has a prescription for
prednisone. the nurse should monitor the client for which of the following. select
all that apply
fluid retention
tremors
hyperglycemia
fever
black, tarry stools
Definition
fluid retention
hyperglycemia
fever
black, tarry stools
Term
a home health nurse is caring for an older adult client who has active TB. the client
lives at home with her husband. she is prescribed the following medication
regimen: isoniazid, rifampin, pyrazinamide, and ethambutol. which of the
following statements indicate that the client understands appropirate care
measure. select all that apply
it is okay to substitute once mdication for another when i run out because they all
fight the infection
i will wash my hands each time i cough or sneeze
i will increase my intake of citrus fruits, red meats, and whole grains
i am glad that i don't have to collect any more sputum specimens
i will make sure that i wear a mask when i am in a public place
i do not need to worry about where i go one i start taking my medication
Definition
i will wash my hands each time i cough or sneeze
i will increase my intake of citrus fruits, red meats, and whole grains
i will make sure that i wear a mask when i am in a public place
Term
a client recently diagnosed with tuberculosis is placed on a multi-medication
regimen. which of the following instructions should the nurse give the client in
regard to ethambutol
your urine may turn a dark orange
watch for a change in the color of your sclera
watch for any changes in vision
take viatmin B6 daily
Definition
watch for any changes in vision
Term
the nurse is caring for a client diagnosed with laryngeal cancer and is admitted
for a total laryngectomy with a right radical neck dissection. the client asks the
nurse if he will be able to speak after the surgery. which of the following is an
appropriate response by the nurse
there is a good chane that you will be able to speak in your natural voice
you will have to use a written form of communication for the rest of your life
you will not be able to speak again with your natural voice, but there are options
for re-establishing speech
the primary concern at this time is to remove the cancer, so you shouldn't worry
about your voice at this time
Definition
you will not be able to speak again with your natural voice, but there are options
for re-establishing speech
Term
after a radical neck dissection, the client reports that he is having difficulty raising
his right arm above his head when dressing. which of the following responses is
appropriate
i wil call your provider and let her know that your right arm is weak
this sometimes occurs as a complication after a radical neck dissection
it is normal for you to be weak after this type of surgery
you may need to wear your arm in a sling the rest of your life
Definition
this sometimes occurs as a complication after a radical neck dissection
Term
which of the following clients are at an increased risk for the development of
laryngeal cancer. select all that apply
a client who paints houses for a living
a client who uses chewing tobacco
a radiology technician who takes xrays of clients daily
a client who smokes only cigars, not cigarettes
a client who lives with a pouse who smokes cigarettes
Definition
a client who paints houses for a living
a client who uses chewing tobacco
a client who smokes only cigars, not cigarettes
a client who lives with a pouse who smokes cigarettes
Term
a nurse in the ED is caring for a client who reports dyspnea and rust colored
sputum that has persisted for nearly 3 weeks. lung cancer is suspected, and
diagnostic tests are ordered. a CT scan reveals the presence of a mass at the
base of the bronchial tree. the client asks "what is a bronchoscopy" an
appropriate response by the nurse is "a bronchoscopy is when
a needle is inserted between two ribs and a piece of the tumor is aspirated
a set of xrays are taken that provide a three dimensional picture of your lungs
magnetic fields and radio waves are used to obtain sectional pictures of your
lungs that outline the tumor
a flexible tube is inserted through your mouth and into your lungs to see the tumor
and obtain a biopsy
Definition
a flexible tube is inserted through your mouth and into your lungs to see the tumor
and obtain a biopsy
Term
a nurse in an ED is caring or a client who has advanced lung cancer. the client
reports dyspnea on exertion and at rest, and her family states that she has
become disoriented over the last 72 hr a chest xray reveals a baseball sized
mediastinal tumor. vital signs are as follows: HR 104, BP 88/42, RR 38, T 100.2 F, SaO2
89% on RA. which of the following do these findings indicate
cardiac tamponade
sick sinus syndrome
superior vena cava syndrome
right heart block
Definition
superior vena cava syndrome
Term
a nurse in an ED is caring or a client who has advanced lung cancer. the client
reports dyspnea on exertion and at rest, and her family states that she has
become disoriented over the last 72 hr a chest xray reveals a baseball sized
mediastinal tumor. vital signs are as follows: HR 104, BP 88/42, RR 38, T 100.2 F, SaO2
89% on RA. which of the following interventions should the nurse implement first
notify the health care provider
obtain a CT scan to determine the exact location of the tumor
administer oxygen
provide family support
Definition
administer oxygen
Term
a nurse is caring for several clients. which of the following clients are at risk for a
pulmonary embolism. select all that apply
a woman who is taking birth control pills
a woman who is postmenopausal
a client who has a fractured femur
a client who smokes one pipe daily
a client who is a marathon runner
a client who has heart failure and chronic a-fib
Definition
a woman who is taking birth control pills
a client who has a fractured femur
a client who smokes one pipe daily
a client who has heart failure and chronic a-fib
Term
a nurse is caring for a milddle adult female client who is admitted to the CCU with
acute dyspnea and dipahoresis. the client states that she is anxious because she
feels that she cannot get enough air. vital signs: hr 117, rr 38, temp 101.2 F, bp
100/54. which of the following actions is the highest prioity
obtain an abg
initiate a heparin drip
administer oxygen therapy
obtain a spiral CT scan
Definition
administer oxygen therapy
Term
a nurse is caring for a client who has a new prescription for heparin therapy. which
of the following statements by the client should pose an immediate concern for
the nurse
i am allergic to morphine
i take antacids several times a day
i had a blood clot in my leg several yeaers ago
it hurts to take a deep breath
Definition
i take antacids several times a day
Term
what is the rationale for this intervention for pulmonary embolism: administer
cyrstalloids
improves cardiac contractility
restores intravascular volume
assesses for thrombocytopenia
Definition
restores intravascular volume
Term
what is the rationale for this intervention for pulmonary embolism: administer
dobutamine
improves cardiac contractility
restores intravascular volume
assesses for thrombocytopenia
Definition
improves cardiac contractility
Term
what is the rationale for this intervention for pulmonary embolism: monitor platelet
count
improves cardiac contractility
restores intravascular volume
assesses for thrombocytopenia
Definition
assesses for thrombocytopenia
Term
a nurse is caring for a client who is to receive fibrinolytic thrombolytic therapy.
which of the following should the nurse recognize aas a contraindication to the
therapy
hip arthroplasty 2 weeks ago
elevated sedimentation rate
incident of exercise-induced asthma 1 week ago
elevated platelet count
Definition
hip arthroplasty 2 weeks ago
Term
a nurse in an ED is caring for a young adult male client who was admitted with a
gunshot wound. the client has a BP 108/55, HR 124, RR 36, temp: 101.4 F, SaO2 95%
on 15 L/min nonrebreather mask. the client reports dyspnea and pain. The nurse
reasses the client 30 min later. which of the following assessment findings should
the nurse report to the health care provider:
SaO2 of 90%
tracheal deviation
headache
bp of 104/54
HR of 154
hemoptysis
distended neck veins
nausea
Definition
SaO2 of 90%
tracheal deviation
HR of 154
hemoptysis
distended neck veins
Term
a nurse is caring for a client who has a tension pneumothorax. the nurse knows
that as a result of the tension pneumothorax, air continues to accumulate and
the intraplueral pressure rises which
causes small blebs to develop in the lung on the affected side
allows air to flow freel through the chest wall during inspiration and expriation
causes less air to enter on inspiration and exceed the barometric pressure
will cause the mediastinum to shift away from the affected side and decrease
venous return
Definition
will cause the mediastinum to shift away from the affected side and decrease
venous return
Term
a nurse in an ED is caring for a 40 year old male client who was admitted following
an MVA. physical assessment reveals absent breath sounds in the left lower lobe.
the client is dyspneic, bp 111/68, hr 124, rr 38, temp 101.4 F, SaO2 of 92% on RA.
which of the following actions should the nurse take first
obtain a chest xray
prepare for chest tube insertion
administer oxygen via high-flow mask
obtain iv access
Definition
administer oxygen via high-flow mask
Term
the client is receiving vecuronium (Norcuron) and is on a ventilator. which of the
following medications should the nurse anticipate administering. select all that
apply
fentanyl
furosemide
midazolam
famotidine
dexamethasone
Definition
midazolam
fentanyl
Term
which of the following clients are at risk for the devlopment of ARF and/or ARDS.
select all that apply
a 14 year old boy who serceived 2 min of CPR following a near drowning incident
a client post coronary artery bypass graft with two chest tubes
a client with a hemoglobin level of 14.5
a client with an exacerbation of cystic fibrosis
a client with dysphagia
a client with a sinus infection
Definition
a 14 year old boy who serceived 2 min of CPR following a near drowning incident
a client post coronary artery bypass graft with two chest tubes
a client with an exacerbation of cystic fibrosis
a client with dysphagia
Term
a nurse is caring for a client who has severe acute respiratory syndrome.
treatment for this client may include. select all that apply
antibiotics
supplemental oxygen
antiviral medications
bronchodilators
intubation
Definition
supplemental oxygen
antiviral medications
intubation
Term
a male client is admitted following an automobile accident. he is very anxious,
dyspneic, and in severe pain. the left chest wall moves in during inspiratoin and
balloons out when he exhales. what condition are these symptoms most
suggestive of
hemothorax
flail chest
atelectasis
pleural effusion
Definition
flail chest
Term
a young man is admitted with a flail chest following a car accident. he is
intubated with an endotracheal tube and is placed on a mechanical ventilator
(control mode, positive pressure). which physical finding alerts the nurse to an
additional problem in repiratory function
dullness to percussion in the third to fifth intercostal space, midclavicular line
decreased paradoxical motion
louder breath sounds on the right chest
pH of 7.36 in arterial blood gases
Definition
louder breath sounds on the right chest
Term
the nurse is caring for a client who has had a chest tube inserted and connected
to a portable water seal drainage. the nurse determines the drainage system is
functioning correctly when which of the following is observed
continuous bubbling in the water seal chamber
fluctuation in the water seal chamber
suction tubing attached to a wall unit
vesicular breath sounds throught the lung fields
Definition
fluctuation in the water seal chamber
Term
the nurse is caring for a client who has just had a chest tube attached to a
portable water seal drainage system
observe for intermittent bubbling in the water-seal chamber
flush the chest tube with 30 to 60 ml of NSS q4 to6 hours
maintain the client in an extreme lateral position
strip the chest tubes in the direction of the client
Definition
observe for intermittent bubbling in the water-seal chamber
Term
the nurse enters the room of a client who has a chest tube attached to a water
seal drainage system and notices the chest tube is dislodged from the chest. what
is the most appropriate nursing interventions
notify the physician
insert a new chest tube
cover the insertion site with petroleum gauze
instruct the client to breath deeply until help arrives
Definition
cover the insertion site with petroleum gauze
Term
an adult is ordered oxygen via nasal prongs. what is true of administering oxygen
this way
mixes room air with oxygen
delivers a precise concentration of oxygen
requires humidity during elivery
is less traumatic to the respiratory tract
Definition
mixes room air with oxygen
Term
an adult is receiving oxygen by nasal prongs. which statement by the client
idnicates that client teaching regarding oxygen therapy has been effective
i was feeling fine so i removed my nasal prongs
it will be good to rest from taking deep breaths now that my oxygen is on
dont' forget to come back quickly when you get me out of bed; i don't like to be
without my oxygen for too long
my family was angry when i told them they could not smoke in my room
Definition
my family was angry when i told them they could not smoke in my room
(well, this is obviously an OLD question!)
Term
the client diagnosed with TB is taught prevention of disease transmission. which
correct answer will the client state is a means of transmission
hands
droplet nuclei
milk products
eating utensils
Definition
droplet nuclei
Term
the treatment plan for a client newly diagnosed with TB is likely to include which
of the following medications as initial treament
ethambutol and isoniazid
streptomycin and penicillin G
tetrcycline and thioridazine
pyrdoxine and tetracycline
Definition
ethambutol and isoniazid
Term
a 64 year old has been smoking since he was 11 years old. he has a long history
of emphysema and is admitted to the hospital because of respiratory infection
that has not improved with outpatient therapy. which finding would the nurse
expect to observe during the client's nursing assessment
electrocardiogram changes
increased anterior-posterior chest diameter
slow, labored respiatory pattern
weight height relationship indicating obesity
Definition
increased anterior-posterior chest diameter
Term
supplemental low flow oxygen therapy is prescribed for a man with emphysema.
which is the most essential action for the nurse to initiate
anticipate the need for humidification
notify the physician that this order is contraindicated
place the client in an upright position
schedule frequent pulse oximeter checks
Definition
schedule frequent pulse oximeter checks
Term
when auscultating the lung fields a sound describes as rustling, like wind in the
trees is heaerd. what is the correct term for this occurence
crackles
rhonchi
wheeze
vesicular
Definition
vesicular
Term
the nurse's assessment of a client with lung cancer reveals the following: copious
secretions, dyspnea, and cough. based on these findings, what is the most
appropriate nursing diagnosis
impaired gas exchange
ineffective airway clearance
pain
altered tissue perfusion
Definition
ineffective airway clearance
Term
a client has just had arterial blood gases drawn. what will the nurse do with the
specimen collected
gently shake the syringe
place the sample in a syringe of warm water
aspirate 0.5 mL of heparin into the syringe
have the specimen analyzed immediately
Definition
have the specimen analyzed immediately
Term
the nurse is to obtain a sputum specimen from a client. select the correct set of
statements instructing the client in the proper technique for obtaining a sputum
specimen
collect the specimen right beore bed. spit carefully into the container
brush your teeth, then cough into the container. do this first thing in the morning
right after lunch, cough and spit into the container
spit into the container then add two tablespoons of water
Definition
brush your teeth, then cough into the container. do this first thing in the morning
Term
the nurse is checking tuberculin skin test results at a health clinic. one client has
an area of induration measuring 12 mm in diameter, what does this finding
indicate
this finding is a normal reading
this finding indicates active TB
this is positive reaction and an indicate exposure to TB
this client needs to come back in two more days and let the nurse look at the
area of induration again
Definition
this is positive reaction and an indicate exposure to TB
Term
an adult has undergone a bronchoscopy. which assessment finding indicate to
the nurse that he is ready for discharge
use of accessory muscles for breathing, decreaed lung sounds
stable vital signs, return of gag and cough reflex
hemoptysis, rhonchi
development of tachycaria with occasional PVCs able to eat and drink
Definition
stable vital signs, return of gag and cough reflex
Term
an adult has a chest tube to a Pleur-evac drainage system attached to a wall
suction. an order to ambulate the client has been received. how should the nurse
ambulate the client safely
clamp the chest tube and carefully ambulate the client a short distance
question the order to ambulate the client
carefully ambulate the client, keeping the pleur-evac lower than the client's chest
disconnect the pleur-evac from the client's chest tube, leave it attached to the
bed, ambulate the client, and then reconnect the chest tube when he is returned
to bed
Definition
carefully ambulate the client, keeping the pleur-evac lower than the client's chest
Term
approximately 10 minutes after a client returns from surgery with a tracheostomy
tube the nurse assesses increaing norisy respiratory and an increased pulse. what
action should be taken immediately
take the client's blood pressure
suction the tracheostomy tube
drain water from the O2 tubing
change the tracheostomy tube
Definition
suction the tracheostomy tube
Term
the nurse will be performing chest physiotherapy (CPT) on a client every 4 hours.
what is the appropriate action by the nurse
gently slap the chest wall
use vibration techniques to move secretions from affected lung areas during the
inspiratoin phase
perform CPT at least 2 hours after meals
plan apical drainage at the beginning of the CPT session
Definition
perform CPT at least 2 hours after meals
Term
a client is on a ventilator. the ventilator alarm goes off. the nurse assesses the client
and observes increased respiratory rate, use of accessory muscles and agitaiton.
what should be the nurse's first action
remove the client from the ventilator and ambubag the client while continuing
to assess to determine the cause of the client's distress
call respiratory therapy to check the ventilator
notify the physician
turn off the alarm
Definition
remove the client from the ventilator and ambubag the client while continuing to
assess to determine the cause of the client's distress
Term
a client with respiratory failure is on a ventilator. the alarm goes off. what should
be the nurse's first action
notify the physician
assess the client to determine the cause of the alarm
turn off the alarm
disconnect the client and use the ambu bag to ventilate the client
Definition
assess the client to determine the cause of the alarm
Term
a nurse is setting up oxygen for an adult male. he is to receive oxygen at 2 L per
nasal cannula. what should be included for this treatment
adjust the flow rate to keep the reservoir bag inflated 2/3 full during inspiration
monitor the client carefully for risk of aspiration
make sure the valves and rubber flaps are patent, functional, and not stuck
remind the client not to use vaseline lip balm
Definition
remind the client not to use vaseline lip balm
Term
a long term COPD client is receiving oxygen at 1 L/min. a family member decides
she "doesn't look too good" and increases her oxygen to 7 L/min. what should the
nurse's initial action be
thank the client's cousin and continue to observe the client
immediately decrease the oygen
notify the physician
add humidity to the oxygen
Definition
immediately decrease the oygen
Term
an adult is receiving oxygen per face mask at 40%. the nurse should include which
of the following in her plan of care
provide good skin care making sure the mask fits well
keep all visitors out of the room
turn off the CPAP during the day
keep the bag inflated at all times
Definition
provide good skin care making sure the mask fits well
Term
an adult has a new tracheostomy in place. He has a small amount of thin white
secretions. the stoma is pink with no drainage noted. how often should the nurse
perform trach care
4 hours
8 hours
24 hours
every hour
Definition
8 hours
Term
a female client is admitted to the hospital. she has smoked two packs per day for
30 years. while providing her history she becomes breathless, pauses frequently
between words, and appears very anxious. she has a cough with thick white
sputum production. her chest is barrel shaped. based on the data, on what
condition will the nurse develop a plan of care
pneumonia
COPD
TB
asthma
Definition
COPD
Term
a 68 year old male is being admitted to the hospital for an exacerbation of his
COPD. what will most likely be included in the plan of care
placed on 10 L of oxygen per NC
placed in repiratory isolation
require frequent rest periods throughout the day
placed on fluid restriction
Definition
require frequent rest periods throughout the day
Term
a client with suspected TB will mot likely relate which clinical manifestations
fatigue, weight loss, low grade fevers, night sweats
asymmetrical chest expansion
rapid shallow breathing, prolonged labored expiration, stridor
dyspnea, hypoxemia, decreased pulmonary compliance
Definition
fatigue, weight loss, low grade fevers, night sweats
Term
an adult is being admitted to the nursing unit with a diagnosis of pneumonia. she
has a history of arrested TB. what will the nurse's initial action
place the client in respiratory isolation
encourage cough and deep breathing
force fluids
administer O2
Definition
place the client in respiratory isolation
Term
an adult is being followed in the outpatient clinic for a dx of active T. she is reciving
isoniazid, rifampin, steptomycin. which statement by the client best indicates she
understands her therapeutic regimen
i'm glad i only have to take these drugs for a couple of weeks
i need to take these two drugs every day and come back to the clinic once a
week for the shot
it may work best to take these pills in the evening right before bed
i'm glad my birth control pills aren't affected by these drugs - the doctor told me
not to get pregnant
Definition
it may work best to take these pills in the evening right before bed
Term
an elderly client has fallen and broken her eighth rib on her left side. the nurse
should include which of the following when developing the plan of care
bind the client's chest with a 6 inche Ace bandage
keep the client on bed rest for 3 days
encourage the client to use her incentive spriometer and cough and deep
breathe
administer large doses of narcotic alagestic so that the client will be able to more
fully participate in pulmonary care
Definition
encourage the client to use her incentive spriometer and cough and deep
breathe
Term
a man is injured in an industrial accident. the industrual nurse assesses him and
observes use of accessory muscles, severe chest pain, agitation, shortness of
breath. the nurse also notices one side of his chest moving differntly than the
other. the nurse suspects flail chest. what will be the nurse's inital action
apply a sandbag to the flail side of his chest
prepare for intubation and mechanical ventilation
prepare for chest tube placement
administer pain medication
Definition
prepare for intubation and mechanical ventilation
Term
what manifestation would the client with pleural effusion display
pain
swelling
dyspnea
increased sputum production
Definition
dyspnea
Term
an 86 year old female was admitted to
the hospital two days ago with pneumonia. she now has an order to be up in the
chair as much as possible. how will the nurse plan the client's morning care
get her up before breakfast. have her eat in the chair, then bathe while still lup
allow her to eat breakfast in bed, rest for 30 minutes, get up in the chair, and rest
for a few minutes. allow her to wash her hands and face - nurse to complete bath
allow her to eat in bed, get her up, and provide her with a pan of water for her
to bathe
get her up before breakfast, have her bathe before breakfast, eat in the chair,
then a rest in the chair
Definition
allow her to eat breakfast in bed, rest for 30 minutes, get up in the chair, and rest
for a few minutes. allow her to wash her hands and face - nurse to complete bath
Term
a client has been admitted to the hospital. lung assessment reveals the following:
bronchial breath sounds over L lower lobe, diminished breath sounds L lower lobe,
tactile fremitus present, percussion dulled in this area. based on the assessment
findings, what condition does the nurse suspect
pneumonia
asthma
emphysema
early left-sided heart failure
Definition
pneumonia
Term
a nurse is teaching a class in a community center about lung cancer. which
statement best demonstrates the client's understanding of the risk factors for lung
cancer
my husband smokes but I don't. so ireally don't need to worry about getting lung
cancer
i guess i will need to eat more green and yellow vegetables
just because i have COPD doesn't mean that i have a higher risk
i've worked with asbestos all my life and have never had any problems
Definition
i guess i will need to eat more green and yellow vegetables
Term
an adult male was diagnosed with lung cancer 18 months ago. he is now in the
terminal stages and is experiencing severe generalized pain. he has ordered
morphine sulfate 10 mg IM q 4-6 h prn. what is the most appropriate action by the
nurse
teach him that the pain medicine prescried will take away all his pain and he will
have no discomfort
cousel him about the addictive qualities of his prescribed narcotic
inform him that he may only ask for the pain medicine every 4 hours and there is
nothing else you can offer in between medication times
encourage him to ask for the pain medicine before the pain becomes severe
Definition
encourage him to ask for the pain medicine before the pain becomes severe
Term
a client is admitted to the nursing unit from the recovery room following a left
pneumonectomy. what will the nurse expect in the plan of care
have a chest tube to water seal
have a chest tube to suction
be monitored closely for respiratory and cardiac complications
have his left arm maintained in a sling to prevent pain and discomfort
Definition
be monitored closely for respiratory and cardiac complications
Term
the nurse may expect a client with suspected early ARDS to exhibit which of the
following
PaO2 of 90, PaCO2 of 45, Xray showing enlarged heart, bradycardia
thick green sputum production, PaO2 of 75, pH 7.45
restlessness, suprasternal retractions PaO2 of 65
wheezes, slow deep respirations, PaCO2 of 55, pH of 7.25
Definition
restlessness, suprasternal retractions PaO2 of 65
Term
the client had a removal of the larynx and a permanent opening made into the
trachea. what is the correct name of this procedure
total laryngectomy
tracheostomy
radical neck dissection
partial laryngectomy
Definition
total laryngectomy
Term
an adult will undergo a total laryngectomy tomorrow. she is concerned about
communicating post op. the nurse should plan for her to communicate by which
method the first 24 - 48 hours after surgery.
using the artificial larynx
writing or pointing on communication board
using esophageal speech
using a voice button
Definition
writing or pointing on communication board
Term
an adult has had a total larngectomy. the nurse is discussing options for verbal
communication with the client. which statement indicatse the client understands
the statement indicates the client understand the available options for verbal
communication
because of the arthritis in my hands, i think the voice button method would be
easiest to use
by the time i leave the hospital i will be able to talk
if i use the esophageal speech, my voice will be high pitched and soft
using an artifical larynx will make me sound sort of monotone
Definition
using an artifical larynx will make me sound sort of monotone
Term
an adult is ready for discharge after undergoing a total laryngectomy. the nurse
is discussing safety aspects of his home care. which statement by the client best
indicates that he understands the safety aspects of his care at home
it is ok to swim as long as i'm careful
i shold use paper tissues to cover my stoma when i'm coughing
i should not wear anyting to cover my stoma
i will need to use a humidifier in my house
Definition
i will need to use a humidifier in my house