MT Flashcards by Nun Ya

A client is concerned about a rash that has developed on their abdomen. What is the nurse’s best response to the client?

a. A rash is similar to infection.”
b. “Inflammation always leads to gangrene.”
c. “A rash is a sequential reaction to injury.”
d. “Rashes indicate the presence of harmful microorganisms that are thriving.”

c.“A rash is a sequential reaction to injury.”

How well did you know this?

Not at all

Perfectly

Diphenhydramine was prescribed to a client with an allergic reaction. The client asks “how does this medication work?” The nurse states “Diphenhydramine works by inhibiting the release of _____________.”

a. Histamine
b. Serotonin
c. Bradykinins
d. Prostaglandins

a. Histamine

How well did you know this?

Not at all

Perfectly

A surgeon’s progress notes indicated “sanguineous drainage on wound gauze.” The nurse’s best description for the drainage is which of the following?

a. Bloody
b. Purulent
c. Clear
d. Thick

a. Bloody

How well did you know this?

Not at all

Perfectly

A trauma nurse is replacing an old chest tube canister filled with clear-pinkish secretions. What is the best description of the exudate the nurse should enter in the progress notes?

a. Catarrhal
b. Hemorrhagic
c. Serosanguineous
d. Sanguineous

c. Serosanguineous

How well did you know this?

Not at all

Perfectly

A wound care nurse is managing a client with Stage IV pressure ulcer. The wound was noted to be foul-smelling with yellowish discharge draining copiously. Which of the following findings is most concerning for the nurse?

a. Purulent discharge
b. Serous secretions
c. Fibrinous plaque
d. Catarrhal drainage

a. Purulent discharge

How well did you know this?

Not at all

Perfectly

A local response to inflammation involved release of histamine. Which of the following are effects of histamine? Select all that apply.

a. Vasoconstriction
b. Edema
c. Redness
d. Heat

b. Edema
c. Redness
d. Heat

How well did you know this?

Not at all

Perfectly

A patient with Pneumothorax underwent emergency insertion of chest tube. Which of the following assessment findings is most concerning to nurse?

a. Bubble arising from the suction control chamber.
b. Drainage is lower than the patient
c. Hemorrhagic secretions 400 ml in the chamber
d. Suction is at -20 cm H2O

c. Hemorrhagic secretions 400 ml in the chamber

How well did you know this?

Not at all

Perfectly

Inflammation involves different transmitters. Which of the following mediators of inflammation causes contraction of smooth muscles? Select all that apply.

a. Complement component
b. Serotonin
c. Kinins
d. Histamine

b. Serotonin
c. Kinins

How well did you know this?

Not at all

Perfectly

According to CDC, in 2004 about 159,000 of all nursing home residents developed pressure ulcers. What are the common causes of pressure ulcers? Select all that apply.

a. Immobility
b. Prolonged moisture exposure
c. Bedbound
d. Shearing forces

How well did you know this?

Not at all

Perfectly

A nurse is preparing a plan of care for a client with a sacral pressure ulcer. What intervention should the nurse include in the client’s care plan to prevent worsening of the ulcer?

a. Frequent repositioning
b. Accurate titration of vasoactive drugs
c. Pain control
d. Proper nutrition

a. Frequent repositioning

How well did you know this?

Not at all

Perfectly

A wound care nurse is conducting a lecture about complications of improper wound healing. Which complication is described as: the creation of connecting wound from original source to adjacent structure?

a. Adhesion
b. Fistula
c. Infection
d. Evisceration

b. Fistula

How well did you know this?

Not at all

Perfectly

A nurse is entering a physician’s request for a wound vacuum into the electronic medical system. Which pressure ulcer is this device being prescribed to treat?

a. Stage I Pressure Ulcer
b. Stage II Pressure Ulcer
c. Mildly draining Stage III Pressure Ulcer
d. Copiously draining Stage IV Pressure Ulcer

d. Copiously draining Stage IV Pressure Ulcer

How well did you know this?

Not at all

Perfectly

A surgeon ordered: “Cleanse Sacral Stage IV Pressure Ulcer with normal saline, apply clean moist gauze with normal saline, cover abdominal pad, secure with tape.” What type of debridement has the physician prescribed to treat this wound?

a. Surgical debridement
b. Mechanical debridement
c. Enzymatic debridement
d. Autolytic debridement

b. Mechanical debridement

How well did you know this?

Not at all

Perfectly

A client with abdominal surgical incision is being investigated for delayed wound healing. Which of the following can cause delayed wound healing? Select all that apply

a. Infection
b. Smoking
c. Advanced age
d. Diabetes Mellitus

How well did you know this?

Not at all

Perfectly

A nurse is documenting a wound assessed on client. What is the accurate pressure ulcer stage for the wound shown below:

a. Stage I
b. Stage II
c. Stage III
d. Stage IV
e. Unstageable
f. Suspected Deep Tissue Injury

f. Suspected Deep Tissue Injury

How well did you know this?

Not at all

Perfectly

A nurse is documenting a wound assessed on client. What is the accurate pressure ulcer stage for the wound shown below:

a. Stage I
b. Stage II
c. Stage III
d. Stage IV
e. Unstageable
f. Suspected Deep Tissue Injury

e. Unstageable

How well did you know this?

Not at all

Perfectly

A nurse performs a wound assessment on a client. How should the nurse document this wound?

a. Stage I
b. Stage II
c. Stage III
d. Stage IV
e. Unstageable
f. Suspected Deep Tissue Injury

d. Stage IV

How well did you know this?

Not at all

Perfectly

A nurse assesses a client’s wound. What pressure ulcer stage should the nurse document for this client?

a. Stage I
b. Stage II
c. Stage III
d. Stage IV
e. Unstageable

c. Stage III

How well did you know this?

Not at all

Perfectly

A nurse assesses a client’s wound. What pressure ulcer stage should the nurse document for this client?

a. Stage I
b. Stage II
c. Stage III
d. Stage IV
e. Unstageable

b. Stage II

How well did you know this?

Not at all

Perfectly

A nurse assesses a client’s wound. What pressure ulcer stage should the nurse document for this client?

a. Stage I
b. Stage II
c. Stage III
d. Stage IV
e. Unstageable

a. Stage I

How well did you know this?

Not at all

Perfectly

Which of the following diets would place a client at the highest risk for macrocytic anemia?

a. Lacto-ovo-vegetarian
b. Lacto-vegetarian
c. Macrobiotic
d. Vegan

d. Vegan

How well did you know this?

Not at all

Perfectly

The nurse is caring for a 50-year-old client in the clinic. The client’s annual physical examination revealed a hemoglobin value of 10 g/dL (100 g/L) compared to 13 g/dL (130 g/L) a year ago. What should be the nurse’s initial action?

a. Encourage intake of over-the-counter iron pills
b. Encourage intake of red meat and egg yolks
c. Facilitate a screening colonoscopy
d. Facilitate another blood test in 6 months

c. Facilitate a screening colonoscopy

How well did you know this?

Not at all

Perfectly

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL (50 g/L). The nurse should anticipate which findings? Select all that apply.

a. Coarse crackles
b. Dyspnea
c. Pallor
d. Respiratory depression
e. Tachycardia

b. Dyspnea
c. Pallor
e. Tachycardia

How well did you know this?

Not at all

Perfectly

The nurse teaches a client diagnosed with iron-deficiency anemia about iron-rich foods. The nurse determines teaching has been effective when the client chooses which of the following meals?

a. Chicken salad with lettuce on French bread, chocolate pudding, and milk
b. Fat-free yogurt, carrot sticks, apple slices, and diet soda
c. Ham, steamed carrots, green beans, gelatin dessert, and iced tea
d. Kale salad with boiled eggs and dried fruit, a brownie, and orange juice

d. Kale salad with boiled eggs and dried fruit, a brownie, and orange juice

How well did you know this?

Not at all

Perfectly

The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD). The nurse anticipates which laboratory results for this client? a. Anemia b. Neutropenia c. Polycythemia d. Thrombocytopenia

c. Polycythemia

A elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client's symptoms? a. Brain natriuretic peptide 70 pg/mL (70 pmol/L) b. Hematocrit 21% (0.21) c. Leukocytes 3,500/mm3 (3.5 x 109/L) d. Platelets 105,000/mm3 (105 x 109/L)

b. Hematocrit 21% (0.21)

A client with polycythemia vera comes to the clinic for treatment. The nurse knows that the monthly treatment for this condition involves which of the following? a. Blood transfusion b. Fluid bolus c. Phlebotomy d. Steroid injection

c. Phlebotomy

The nurse plans discharge teaching for a client newly diagnosed with polycythemia vera. Which actions will the nurse include in the teaching plan? Select all that apply. a. Elevate the legs and feet when sitting b. Increase dietary intake of foods rich in iron c. Increase fluid intake during exercise and hot weather d. Increase water temperature to reduce post-bath itching e. Report swelling or tenderness in the legs

a. Elevate the legs and feet when sitting c. Increase fluid intake during exercise and hot weather e. Report swelling or tenderness in the legs

A medical surgical nurse has been assigned to four patients in the unit. Which assessment findings should the nurse report to the physician? a. Iron Deficiency Anemia, Colorectal Cancer Hemoglobin 4.1 gm/dl b. Acute Myelocytic Leukemia with a WBC of 55,000 c. Sickle-Cell Disease, receiving treatment for Acute Vaso-Occlusive Crisis d. Aplastic Anemia with a Platelet level of 75,000

a. Iron Deficiency Anemia, Colorectal Cancer Hemoglobin 4.1 gm/dl

A nurse received a low hemoglobin level for a patient. Which of the following is the most likely diagnosis for the patient? a. Iron Deficiency Anemia b. Megaloblastic Anemia c. Sideroblastic Anemia d. Thalassemia

a. Iron Deficiency Anemia

A male client (75 kg) diagnosed with Acute Myelocytic Leukemia is to receive Bleomycin (Cytotoxic glycopeptide) which comes in 30 units/100 ml. The physician ordered 0.5 units/kg via intravenous route. How many total ml of drug should the patient receive? a. 123 cc b. 125 cc c. 127 cc d. 129 cc

b. 125 cc

A client (80 Kg) with Sickle Cell Anemia is ordered transfusion of packed RBC for a hemoglobin level of 6.8 gms/dl. The blood product has a total volume of 375 ml. The hematologist ordered to transfuse in 4 hours. How many ml per hour should the nurse a. 93.75 ml/hr b. 72.55 ml/hr c. 51.2 ml/hr d. 87.8 ml/hr

a. 93.75 ml/hr

Which of the following blood cancers is most commonly associated with younger clients? a. Acute Myelocytic Leukemia b. Acute Lymphocytic Leukemia c. Chronic Myelocytic Leukemia d. Chronic Lymphocytic Leukemia

b. Acute Lymphocytic Leukemia

A 27-year-old male client informed their health care provider that they were diagnosed with leukemia but has been in remission for many years. The nurse obtaining the history is aware that the client was most likely diagnosed with which of the following types of leukemia? a. Acute Myelocytic Leukemia b. Acute Lymphocytic Leukemia c. Chronic Myelocytic Leukemia d. Chronic Lymphocytic Leukemia

b. Acute Lymphocytic Leukemia

A client with Sickle Cell Disease was recently admitted in the Medical-Surgical Ward at Queen of the Valley Hospital. The nurse formulating nursing diagnoses should include which of the following as a priority? a. Acute Pain b. Anxiety c. Ineffective tissue perfusion d. Activity intolerance

c. Ineffective tissue perfusion

A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply. a. Amphetamine use b. Cigarette smoking c. Cold exposure d. Deep sleep e. Sexual intercourse

a. Amphetamine use b. Cigarette smoking e. Sexual intercourse

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off? a. Hematocrit of 30% b. Partial thromboplastin time of 110 seconds c. Platelet count of 80,000/mm3 (80 x 109/L) d. Prothrombin time of 11 seconds

b. Partial thromboplastin time of 110 seconds

An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit. The new RN is measuring orthostatic blood pressure (BP) for a client. Which situation would warrant intervention by the experienced nurse? a. Nurse has client lie supine for 5-10 minutes prior to starting procedure b. Nurse interprets a decrease in systolic BP by 10 mm Hg as a normal finding c. Nurse starts by measuring BP and heart rate (HR) with the client standing d. Nurse takes BP and HR after standing at 1- and 3-minute intervals

c. Nurse starts by measuring BP and heart rate (HR) with the client standing

A client develops sinus bradycardia with blood pressure of 90/40 mm Hg and a heart rate of 46/min. Which of the following actions should the nurse take? a. Give scheduled dose of metoprolol 50 mg orally b. Instruct client to cough forcefully c. Place client in reverse Trendelenburg position d. Prepare to administer atropine 0.5 mg intravenous (IV) push

d. Prepare to administer atropine 0.5 mg intravenous (IV) push

The clinic nurse is providing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client? a. How to transmit the readings over the phone b. Keep a diary of activities and any symptoms experienced c. Refrain from exercising while wearing the monitor d. The monitor may be removed only when bathing

b. Keep a diary of activities and any symptoms experienced

A registered nurse is making pre-procedure phone calls to clients scheduled for cardiac pharmacologic nuclear stress testing the following day. Which instructions should the nurse give the clients? Select all that apply. a. Decaffeinated coffee or tea can be consumed b. Do not consume caffeine for 24 hours before the test c. Do not smoke on the day of the test d. Do not take beta blockers on the day of the test e. Take diabetic medications as usual before the test

b. Do not consume caffeine for 24 hours before the test c. Do not smoke on the day of the test d. Do not take beta blockers on the day of the test

A nurse is making initial client rounds at the beginning of the shift. Which client should the nurse see first? a. 36-year-old client with endocarditis who has a temperature of 100.6 F (38.1 C), chills, malaise, and a heart murmur b. 40-year-old client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distension c. 67-year-old client admitted for pneumonia with new-onset atrial fibrillation, who has blood pressure of 130/90 mm Hg and heart rate of 110/min d. 70-year-old client with advanced heart failure who is receiving intravenous (IV) diuretics, has blood pressure of 80/60 mm Hg, and is watching TV

b. 40-year-old client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distension

The nurse is caring for a client with newly diagnosed infective endocarditis (IE). Which assessment finding by the nurse is the highest priority to report to the health care provider (HCP)? a. Pain and pallor in one foot b. Pain in both knees c. Splinter hemorrhages in the nail beds d. Temperature of 102.2 F (39 C)

a. Pain and pallor in one foot

The nurse should plan to teach which client about the need for prophylactic antibiotics prior to dental procedures? a. Client who had a large anterior wall myocardial infarction (MI) with subsequent heart failure b. Client who had a mitral valvuloplasty repair c. Client with a mechanical aortic valve replacement d. Client with mitral valve prolapse with regurgitation

c. Client with a mechanical aortic valve replacement

A client is in suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion? Select all that apply. a. Apical pulse b. Capillary refill c. Lung sounds d. Pupillary response e. Skin color and temperature

b. Capillary refill e. Skin color and temperature

A client with an implantable cardioverter defibrillator (ICD) develops ventricular tachycardia (VT) with a pulse while admitted to the medical-surgical unit. The ICD fires multiple times without successfully stopping the VT, causing the client to become confused and difficult to rouse. Which action by the nurse is appropriate? a. Attempt to stimulate a vagal response by having the client cough b. Deactivate the client's implantable cardioverter defibrillator with an external magnet c. Obtain a STAT 12-lead ECG to verify the cardiac rhythm d. Prepare for synchronized cardioversion with the external defibrillator

d. Prepare for synchronized cardioversion with the external defibrillator

The nurse is caring for a client who just had a permanent ventricular pacemaker inserted. The nurse observes the cardiac monitor and sees a pacing spike followed by a QRS complex for each heartbeat. How should the nurse assess for mechanical capture of the pacemaker? a. Auscultate the client's lungs sounds b. Measure the client's blood pressure c. Obtain a 12-lead ECG d. Palpate the client's radial pulse rate

d. Palpate the client's radial pulse rate

The nurse is planning discharge teaching for a client who just received a permanent pacemaker. Which topics should the nurse include? Select all that apply. a. Avoid MRI scans b. Do not place cell phones directly over the pacemaker c. Notify airport security when traveling d. Perform shoulder range-of-motion exercises e. Refrain from using microwave ovens

a. Avoid MRI scans b. Do not place cell phones directly over the pacemaker c. Notify airport security when traveling

A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse explains that the pain will improve with which of the following? a. Coughing and deep breathing b. Left lateral position c. Pursed-lip breathing d. Sitting up and leaning forward

d. Sitting up and leaning forward

The nurse receives handoff of care report on four clients. Which client should the nurse see first? a. Client with atrial fibrillation who reports feeling palpitations and has an irregular pulse of 122/min b. Client with liver cirrhosis who reports bleeding from an IV insertion site and has a platelet count of 48,000 mm3 (48 x 109/L) c. Client with pericarditis whose blood pressure has decreased from 122/70 mm Hg to 98/68 mm Hg over the past hour d. Client with pneumonia whose white blood cell count has increased from 14,000 mm3 (14 x 109/L) 8 hours ago to 30,000 mm3 (30 x 109/L)

c. Client with pericarditis whose blood pressure has decreased from 122/70 mm Hg to 98/68 mm Hg over the past hour

A parent calls the nursing triage line during the evening. The parent says that a 7-year-old was found playing in an area with poison ivy and asks what to do. Which is the most important instruction to give the parent? a. Apply cool, wet compresses for itching b. Apply topical cortisone ointment to the area c. Discourage the child from scratching the area d. Wash the skin where the contact occurred

d. Wash the skin where the contact occurred

The nurse assesses the sacral wound of a newly admitted client. How should the nurse document the wound? Picture 1.png a. Stage 2 pressure injury b. Stage 3 pressure injury c. Suspected deep-tissue injury d. Unstageable pressure injury

d. Unstageable pressure injury

The nurse is assessing a 2-year-old who has a blistered sunburn across the back and shoulders. Which of the following parent statements indicates an appropriate understanding of care for sunburn? Select all that apply. a. "I am allowing my child to play outdoors only very early in the morning and late in the evening since the sunburn." b. "I am encouraging extra fluids since my child got sunburned." c. "I have been giving my child acetaminophen to help relieve the pain." d. "I have been placing cool, wet washcloths on my child's back." e. "I have rubbed hydrocortisone cream on the area to help reduce inflammation and promote healing."

a. "I am allowing my child to play outdoors only very early in the morning and late in the evening since the sunburn." b. "I am encouraging extra fluids since my child got sunburned." c. "I have been giving my child acetaminophen to help relieve the pain." d. "I have been placing cool, wet washcloths on my child's back."

The nurse is conducting an educational community outreach program on melanoma screening. Which statement by a resident indicates the need for further education? a. "Abrupt changes in the size or color of a mole are warning signs." b. "All new growths and pigmentations must be biopsied to rule out cancer." c. "Melanoma can occur as multiple different colors." d. "Melanoma does not always occur as a new mole."

b. "All new growths and pigmentations must be biopsied to rule out cancer."

The nurse is caring for a client with hemophilia admitted for a facial laceration and hemarthrosis of the left knee after falling at home. Which of the following actions by the nurse are appropriate? Select all that apply. a. Administers coagulation factor replacement IV push b. Administers ibuprofen PO PRN for pain c. Applies ice packs to the affected joint hourly for 15 minutes d. Elevates the affected leg in the extended position e. Performs neurologic assessment every 30 minutes for 6 hours

a. Administers coagulation factor replacement IV push c. Applies ice packs to the affected joint hourly for 15 minutes d. Elevates the affected leg in the extended position e. Performs neurologic assessment every 30 minutes for 6 hours

The nurse provides home care education to a client newly diagnosed with von Willebrand disease. Which of the following client statements demonstrate correct understanding of the education? Select all that apply. a. "I can use a humidifier to help prevent nosebleeds." b. "I need to avoid contact sports such as soccer or hockey." c. "I should use a soft-bristled toothbrush and floss carefully." d. "I will call my health care provider if I soak a menstrual pad every hour." e. "I will take naproxen to decrease inflammation if I am injured."

a. "I can use a humidifier to help prevent nosebleeds." b. "I need to avoid contact sports such as soccer or hockey." c. "I should use a soft-bristled toothbrush and floss carefully." d. "I will call my health care provider if I soak a menstrual pad every hour."

The nurse provides care for a client diagnosed with polycythemia vera. Which statement by the client would require immediate follow-up? a. "I am trying to find makeup to cover my unattractive, ruddy facial complexion." b. "I must have injured my leg in some way. It is sore, swollen, and red." c. "I take a baby aspirin to relieve my occasional headaches." d. "My skin itches so severely, and no lotion or cream seems to help.

b. "I must have injured my leg in some way. It is sore, swollen, and red."

A medical surgical nurse is attending to four patients in the unit. Which assessment findings should the nurse report to the physician?  a. Iron Deficiency Anemia, Colorectal Cancer Hemoglobin 4.1 gm/dl b. Acute Myelocytic Leukemia, WBC: 55,000 c. Sickle-Cell Disease, Acute Vaso-Occlusive Crisis d. Aplastic Anemia, Platelets 75,000

a. Iron Deficiency Anemia, Colorectal Cancer Hemoglobin 4.1 gm/dl

A nurse received a low hemoglobin level for a patient. Which of the following is the most likely diagnosis for the patient?  a. Iron Deficiency Anemia b. Megaloblastic Anemia c. Sideroblastic Anemia d. Thalassemia

a. Iron Deficiency Anemia

A 27-year-old male client informed his health care provider that he was once diagnosed with leukemia but has been in remission for many years. The nurse obtaining the history is aware that which type of leukemia is the most likely type? a. Acute Myelocytic Leukemia b. Acute Lymphocytic Leukemia c. Chronic Myelocytic leukemia d. Chronic Lymphocytic Leukemia

b. Acute Lymphocytic Leukemia

The nurse responds to a call for help from another staff member. Upon entering the client’s room, the nurse observes an unlicensed assistive personnel (UAP) performing chest compressions on an unconscious adult client while another nurse is calling for the emergency response team. What action by the arriving nurse is the priority? 1. Ask the UAP to stop compressions and check for a pulse 2. Establish additional IV access with large-bore IVs 3. Obtain the defibrillator and apply the pads to the client’s chest 4. Prepare to administer 100% O2 with a bag valve mask

3. Obtain the defibrillator and apply the pads to the client’s chest

The nurse is caring for a client after percutaneous placement of a coronary stent for a myocardial infarction. The client rates lower back pain as 5 on a scale of 0-10 and has blood pressure of 140/92 mmHg. The cardiac monitor shows normal sinus rhythm with occasional premature ventricular contractions. Which prescription should the nurse administer first? Potassium 3.3 | Sodium 149 | Glucose 157 1. Captopril PO every 8 hours 2. Morphine IV PRN for pain 3. Potassium chloride IVPB once 4. Regular insulin subcutaneous with meals

3. Potassium chloride IVPB once

A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider (HCP). which assessment data is most important for the nurse to report to the HCP? 12 1. Blood pressure (BP) of 140/86 mm Hg 2. Difficulty swallowing 3. Dry, hacking cough 4. Low back pain

2. Difficulty swallowing

The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythm first? 1. Atrial fibrillation with a pulse of 76/min in a client prescribed rivaroxaban 2. Bradycardia in a client with a demand pacemaker set at 70/min 3. First-degree atrioventricular block in a client prescribed atenolol 4. Sinus tachycardia in a client with gastroenteritis and dehydration

2. Bradycardia in a client with a demand pacemaker set at 70/min

A nurse cares for a client after cardiac catheterization. During assessment of the groin site, the nurse notices that the dressing is saturated with blood and a small trickle leaks down the client’s leg. What should the nurse do first? 1. Apply direct manual pressure at and above the skin puncture site 2. Call the health care provider to report active bleeding 3. Check the peripheral pulse distal to the catheterization site 4. Place a new pressure dressing over the catheterization site

1. Apply direct manual pressure at and above the skin puncture site

A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first? 1. Auscultate breath sounds 2. Check for peripheral edema 3. Measure the client’s vital signs 4. Review the client’s weight log over the past several days

1. Auscultate breath sounds

A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective? 1. I’m not worried about the device firing now because I know it won’t hurt. 2. I will let my daughter fix my hair until my health care provider says I can do it 3. I will looks into public transportation because I won’t be able to drive again 4. I will notify my travel agent that I can no longer travel by plane

2. I will let my daughter fix my hair until my health care provider says I can do it

The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report. Which client should the nurse assess first? 1. 2 days post abdominal aortic aneurysm repair with a pedal pulse decreased from baseline 2. 2 days post coronary bypass graft surgery with a while blood cell count of 18,000/mm3 3. Cardiomyopathy with an ejection fraction of 25% and dyspnea on exertion 4. Pneumothorax with a chest tube to negative suction and subcutaneous emphysema

1. 2 days post abdominal aortic aneurysm repair with a pedal pulse decreased from baseline

Which client is in need of follow-up education by the nurse? 1. Client with peripheral arterial disease (PAD) who insists on dangling leg over the side of the bed when sleeping 2. Client with Raynaud’s phenomenon who routinely soaks hands in warm water before going out 3. Client with venous leg ulcer who refuses to wear elastic compression stockings during the day 4. Postsurgical client who points and flexes feet when lying in bed

3. Client with venous leg ulcer who refuses to wear elastic compression stockings during the day

A client with peripheral arterial disease is visiting the health clinic. The nurse completes a health assessment. Which statement by the client indicates a priority need for follow-up teaching? 1. I always take my simvastatin in the evening 2. I prop my legs up in the recliner and use a heating pad when my feet are cold 3. I’ve been walking on my treadmill at home for 15 minutes each day 4. I’ve noticed that I don’t have much hair on my lower legs anymore

2. I prop my legs up in the recliner and use a heating pad when my feet are cold

During assessment of a client who underwent a coronary artery bypass graft 10 hours ago, the nurse notes that the amount of drainage from the mediastinal chest tube has decreased from 100 mL to 20 mL over the last hour. Which of the following nursing actions is appropriate? 1. Auscultate the client’s heart sounds 2. Notify the client’s health care provider 3. Position the tubing with a dependent loop 4. Strip the chest tube to remove possible clots

1. Auscultate the client’s heart sounds

What clinical symptoms might the nurse expect to find in a client with a central venous pressure (CVP) of 24 mm Hg? SATA 1. Crackles in lungs 2. Dry mucous membranes 3. Hypotension 4. Jugular venous distention 5. Pedal edema

1. Crackles in lungs 4. Jugular venous distention 5. Pedal edema

The nurse is caring for a client who just had aortic valve replacement surgery. Which assessment information is most important to report to the health care provider (HCP)? 1. Chest tube output of 175 mL in past hour 2. International Normalized Ratio (INR) of 1.5 3. Temperature of 100.3F 4. Total urine output of 85 mL over past 3 hours

1. Chest tube output of 175 mL in past hour

The nurse is caring for a client on the organ donation waiting list for cardiac transplantation. Which teaching topic is most important for the nurse to emphasize at this time? 1. Immunosuppressive therapy as a lifelong commitment 2. Importance of accurate daily weight monitoring 3. Importance of periodic endomyocardial biopsies 4. Maintenance of meticulous surgical incision care

1. Immunosuppressive therapy as a lifelong commitment

The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack (TIA). the client’s blood pressure today is 170/88 mm Hg. What teaching topic is a priority for the nurse to discuss with this client? 1. Decreasing sodium intake 2. Decreasing stress levels at work and home 3. Increasing activity level 4. Taking blood pressure medications as prescribed

4. Taking blood pressure medications as prescribed

The nurse is caring for a client diagnosed with a deep venous thrombosis 1 day ago. Which action by the client would require an immediate intervention by the nurse? 1. Ambulates through the hallway several times per day 2. Applies a warm compress to the site of inflammation 3. Elevates the limb above the level of the heart while in bed 4. Massages the affected leg to reduce pain and swelling

4. Massages the affected leg to reduce pain and swelling

The nurse is monitoring a client following a radiofrequency catheter ablation. The nurse notes that the P waves are not associated with the QRS complexes on the cardiac monitor. Which intervention is most appropriate at this time? 1. Call a code and begin chest compressions 2. Call the rapid response team and prepare for cardioversion 3. Document the findings in the chart and continue to monitor 4. Notify the cardiologist and prepare for temporary pacing

4. Notify the cardiologist and prepare for temporary pacing

A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min. IV fluids of 2-liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred? 1. Capillary refill is less than 3 seconds 2. Pulse pressure is narrowed 3. Systolic blood pressure drops only when standing 4. Urine output is 360 mL in 4 hours 5. Urine specific gravity is 1.020

1. Capillary refill is less than 3 seconds 4. Urine output is 360 mL in 4 hours 5. Urine specific gravity is 1.020

An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit. Which assessment technique by the new nurse requires intervention by the RN? 1. Nurse carefully auscultates for heart murmurs at Erb’s point 2. Nurse palpates bilateral carotid arteries simultaneously to assess for symmetry 3. Nurse places client in semi-fowler’s position to assess for jugular venous distension 4. Nurse positions client supine to assess the point of maximal impulse

2. Nurse palpates bilateral carotid arteries simultaneously to assess for symmetry

The nurse is preparing to administer 40 mg of IV furosemide. Prior to administering the medication, the nurse should assess which parameters? SATA 1. Blood pressure 2. Blood urea nitrogen 3. Liver enzymes 4. Potassium 5. White blood cell count

1. Blood pressure 2. Blood urea nitrogen 4. Potassium

A client is hospitalized with worsening chronic heart failure. Which clinical manifestations does the admitting nurse most likely assess in this client? SATA 1. Crackles on auscultation 2. Dry mucous membranes 3. Increased jugular venous distention 4. Rhonchi on auscultation 5. Skin “tenting” 6. 3+ pitting edema of the lower extremities

1. Crackles on auscultation 3. Increased jugular venous distention 6. 3+ pitting edema of the lower extremities

The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis. Which of the following clinical manifestations should the nurse expect? SATA 1. Blue, cyanotic toes 2. Calf pain 3. Dry, shiny, hairless skin 4. Lower leg warmth and redness 5. Unilateral leg edema

2. Calf pain 4. Lower leg warmth and redness 5. Unilateral leg edema

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment findings would indicate possible graft leakage and require a report to the primary care provider? SATA 1. Ecchymosis of the scrotum 2. Increased abdominal girth 3. Increased urinary output 4. Report of groin pain 5. Report of increased thirst and appetite loss

1. Ecchymosis of the scrotum 2. Increased abdominal girth 4. Report of groin pain

The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but not shock is advised. Which action should the nurse perform next? 1. Check for a carotid pulse for at least 10 seconds 2. Provide rescue breaths at a rate of 10-12/min 3. Resume chest compressions at a rate of 100/min 4. Use the jaw-thrust maneuver to assess the airway

3. Resume chest compressions at a rate of 100/min

The nurse is admitting a client from the post-anesthesia care unit who just received a permanent atrioventricular pacemaker for a complete heart block. Which action should the nurse implement first? 1. Assess incision for bleeding or hematoma formation 2. Auscultate bilateral anterior and posterior lung sounds 3. Initiate continuous cardiac monitoring 4. Reestablish IV fluids and postoperative antibiotics

3. Initiate continuous cardiac monitoring

A nurse is caring for a client on the first day postop after having minimally invasive direct coronary artery bypass (MIDCAB) grafting. The client thought that this surgery was supposed to have a much easier recovery and asks the nurse why it is so painful to take deep breaths. What is the best response by the nurse? 1. I am sorry you have so much pain. I’ll go get your pain medication right now. 2. Let me call the health care provider (HCP) to see if we can increase the dose of your pain medicine 3. Take deep breaths while splinting your chest with a pillow, and use you incentive spirometer every 2 hours. This will help your recovery. 4. The overall recovery time is expected to be shorter, but initial postop pain can actually be higher with MIDCAB because the incision are made between the ribs

4. The overall recovery time is expected to be shorter, but initial postop pain can actually be higher with MIDCAB because the incision are made between the ribs

The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary hypertension. What clinical manifestations are most likely to be assessed? SATA 1. Crackles in lung bases 2. Increased abdominal girth 3. Jugular venous distention 4. Lower extremity edema 5. Orthopnea

2. Increased abdominal girth 3. Jugular venous distention 4. Lower extremity edema

The nurse is caring for a client who had a large anterior wall myocardial infarction (MI) 24 hours ago. Which finding is most important to report to the health care provider (HCP)? 1. Nausea and vomiting 2. New S3 heart sound 3. Occasional unifocal premature ventricular contractions (PVCs) 4. Temperature of 100.4F

2. New S3 heart sound

A client with mitral valve prolapse (MVP) has been experiencing occasional palpitations, lightheadedness, and dizziness. The health care provider prescribes a beta blocker. What additional teaching should the nurse include for this client? 1. Avoid aerobic exercise 2. Ensure you receive antibiotics prior to dental work 3. Stay well hydrated and avoid caffeine 4. Wear a medical alert bracelet

3. Stay well hydrated and avoid caffeine

A client with chronic heart failure calls the clinic reports a weight gain of 3 lb over the last 2 days. Which information is most important for the nurse to ask this client? 1. Diet recall for this current week 2. Fluid intake for the past 2 days 3. Medications and dosages taken over the past 2 days 4. Presence of shortness of breath, coughing, or edema

4. Presence of shortness of breath, coughing, or edema

The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which introductions should the nurse include? SATA 1. Avoid excessive caffeine 2. Immerse hands in cold water 3. Practice yoga or tai chi 4. Refrain from using tobacco products 5. Wear gloves when handling cold objects

1. Avoid excessive caffeine 3. Practice yoga or tai chi 4. Refrain from using tobacco products 5. Wear gloves when handling cold objects

The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention? 1. The client cannot remember what was done yesterday 2. The client has a painful red area on the buttocks 3. The client has new dependent edema of the feet 4. The client has strong, foul smelling urine

3. The client has new dependent edema of the feet

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2F, blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? 1. Arterial blood gasses (ABGs) 2. B-type natriuretic peptide (BNP) 3. Cardiac enzymes (CK-MB) 4. Chest x-ray

2. B-type natriuretic peptide (BNP)

A critical care nurse is caring for a newly admitted client with acute aortic dissection. Which prescription should the nurse prioritize while awaiting surgical revision of the client’s aortic dissection? 1. Administer IV labetalol to maintain blood pressure within prescribed parameters 2. Initiate and maintain strict bed rest and a low-stimulation environment 3. Monitor bilateral lower extremity peripheral pulse strength 4. Prepare the client’s consent form for surgical repair of the aorta

1. Administer IV labetalol to maintain blood pressure within prescribed parameters

The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse? 1. Glucose 200 mg/dL 2. Hematocrit 38% 3. Potassium 3.4 mEq/L 4. Troponin 0.7 ng/mL

4. Troponin 0.7 ng/mL

\*\*An elderly client tells the nurse “I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking.” What is the priority assessment the nurse should perform? 1. Assess for dry, scaly skin on the lower legs 2. Assess for presence or absence of hair growth on lower extremities 3. Check for presence and quality of posterior tibial and dorsalis pedis pulses 4. Obtain a dietary history

3. Check for presence and quality of posterior tibial and dorsalis pedis pulses

Which interventions should the nurse include when caring for a client who has had endovascular repair of an abdominal aortic aneurysm? SATA 1. Assess abdominal incision every 4 hours 2. Check for bleeding at groin puncture sites 3. Measure chest tube drainage 4. Monitor fluid intake and urine output 5. Palpate and monitor peripheral pulses

2. Check for bleeding at groin puncture sites 4. Monitor fluid intake and urine output 5. Palpate and monitor peripheral pulses

The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an abnormal mean arterial pressure (MAP). The nurse will need to notify the HCP about which client? 1. A client from the cardiac catheterization lab with a blood pressure (BP) of 102/58 mm Hg 2. A client just admitted from the emergency department with a BP of 150/72 mm Hg 3. A client with a BP of 92/60 mm Hg who just received a dose of nitroglycerin 4. A client with heart failure on metoprolol with a BP of 106/42 mm Hg

4. A client with heart failure on metoprolol with a BP of 106/42 mm Hg

A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client? 1. Bronchial breath sounds at lung periphery 2. Clear vesicular breath sounds at lung bases 3. Diffuse bilateral crackles at lung bases 4. Strider in upper airways

3. Diffuse bilateral crackles at lung bases

A 62 year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago. The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is the priority? 1. Ask the client how long the leg has been tender and warm 2. Assess the electrocardiogram (ECG) for any ectopic beats 3. Check vital signs including pulse oximetry 4. Complete neurovascular assessment on lower extremities

4. Complete neurovascular assessment on lower extremities

A client comes to the emergency department with crushing, substernal chest pain. Temperature is 98.6F, blood pressure is 173/84 mm Hg, pulse is 92/min, and respirations are 24/min. Oxygen saturation is 95% on room air. What is the nurse’s next priority action? 1. Attach defibrillator pads to the client’s chest 2. Check the lipid profile laboratory results 3. Obtain a 12-lead electrocardiogram (ECG) 4. Prepare to administer a heparin drip

3. Obtain a 12-lead electrocardiogram (ECG)

The nurse has just completed discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective? 1. I’m glad that I can continue taking my Ginkgo biloba 2. I will increase my intake of leafy green vegetables 3. I will start applying vitamin E to my chest incision after showering 4. I will shave with an electric razor from now on

4. I will shave with an electric razor from now on

The nurse has just completed discharge teaching for a client recently diagnosed with hypertension. Which of the following statements by the client indicate understanding of the Dietary Approaches to Stop Hypertension (DASH) diet? SATA 1. I need to eat less red meat and more fresh vegetables 2. I’ll limit drinking soda to only one at a time as an occasional treat 3. I’m going to replace potato chips with fruit during meals and snacking 4. I’m really going to miss drinking as much milk as I normally do 5. Taking the salt shaker off the table should be enough to reduce my sodium intake

1. I need to eat less red meat and more fresh vegetables 2. I’ll limit drinking soda to only one at a time as an occasional treat 3. I’m going to replace potato chips with fruit during meals and snacking

A nurse is discussing discharge education with a client after his fifth hospitalization for pulmonary edema caused by his congestive heart failure. Which of the following statements indicates that further teaching is required? 1. I should supplement my potassium intake 2. I should weigh myself daily 3. Moderate exercise may be helpful in my condition 4. Potato chips are an acceptable snack in moderation

4. Potato chips are an acceptable snack in moderation

A client with heart failure has gained 5 lbs over the last 3 days. The nurse reviews the client’s blood laboratory results. Based on this information, what medication administration does the nurse anticipate? Sodium 126 Potassium 4.8 Calcium 9.0 1. 0.45% sodium chloride IV 2. Calcium gluconate18 3. Furosemide 4. Sodium polystyrene sulfonate

3. Furosemide

The nurse receives hand-off report on assigned clients. Which client should the nurse assess first? 1. Client 1 day post femoral-popliteal bypass surgery who now has a nonpalpable pedal pulse present only with Doppler 2. Client with chronic venous insufficiency who has edema and brown discoloration of the lower extremities 3. Client with peripheral arterial disease and gangrene of the foot who has a cool-to-the-touch, hairless extremity 4. Client with peripheral arterial disease who reports severe cramping in the calf with activity such as walking

1. Client 1 day post femoral-popliteal bypass surgery who now has a nonpalpable pedal pulse present only with Doppler

A client with myocardial infarction (MI) underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider (HCP) about resuming sexual relations after an MI. What teaching should the nurse initiate with this client? 1. If the client is able to climb 2 flight of stairs without symptoms, the client may be ready for sexual activity if approved by the HCP 2. Inform the client that medications such as sildenafil or tadalafil are available as prescriptions from the HCP 3. It will be 6 months before the heart is healthy enough for sexual activity 4. The client will be ready for sexual activity after completion of cardiac rehabilitation

1. If the client is able to climb 2 flight of stairs without symptoms, the client may be ready for sexual activity if approved by the HCP

A nurse in the intensive care unit is caring for postoperative cardiac transplant client. What intervention is most important to include in the plan of care? 1. Apply sequential compression devices to prevent deep vein thrombosis 2. Assist client to change positions slowly to prevent hypotension 3. Encourage coughing and deep breathing to prevent pneumonia 4. Use careful hand washing and aseptic technique to prevent infection

4. Use careful hand washing and aseptic technique to prevent infection

A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time? 1. Avoid strenuous activity before the surgery 2. Continue to exercise, even if angina occurs. It will strengthen your heart muscles. 3. Take short walks 3 times a day 4. There are no activity restrictions unless angina occurs

1. Avoid strenuous activity before the surgery

The nurse cares for a transgender client who is prescribed estrogen therapy. Which side effect is most important for the nurse to report to the health care provider? 1. Breast tenderness 2. Generalized weight gain 3. Leg swelling 4. Nausea and vomiting

3. Leg swelling

A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation? 1. 10 mg isosorbide dinitrate twice daily 2. 20 mg atorvastatin once daily 3. 500 mg naproxen twice daily 4. 2,000 mg fish oil once daily

3. 500 mg naproxen twice daily

A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse’s first action? 1. Auscultate the client’s breath sounds 2. Encourage the client to increase fluid intake 3. Report the findings to the health care provider (HCP) 4. Start an intravenous line for diuretic administration

1. Auscultate the client’s breath sounds

A client admitted to the cardiac care unit with markedly elevated blood pressure and heart failure is receiving a continuous infusion of nitroprusside. Thirty minutes later, the client appears pale with cold, clammy skin and reports being lightheaded. Which is the priority nursing action? 1. Auscultate the client’s lungs 2. Check the client’s capillary refill 3. Measure the client’s blood pressure 4. Review the client’s electrocardiogram (ECG)

3. Measure the client’s blood pressure

The nurse identifies which risk factors as contributing to the development of peripheral artery disease? SATA 1. Cigarette smoking 2. Diabetes mellitus 3. Hyperlipidemia 4. Oral contraceptive use 5. Prolonged standing

1. Cigarette smoking 2. Diabetes mellitus 3. Hyperlipidemia

A nurse on the telemetry unit observes the following rhythm on the monitor of a client admitted with coronary artery disease. What action should the nurse take first? 1. Administer atropine 0.5 mg IV push 2. Measure the client’s vital signs 3. Move the client back to bed from chair 4. Obtain a temporary pacemaker

2. Measure the client’s vital signs

The nurse is assessing a client with a possible diagnosis of peripheral artery disease. Which client statement is consistent with the diagnosis? 1. At the end of the day, my shoes and socks are tight 2. I have a slow-healing sore right above my ankle 3. My legs ache when I stand for extended periods 4. When I sit down to rests and elevate my legs, the pain increases

4. When I sit down to rests and elevate my legs, the pain increases

The charge nurse is assisting with a non emergent cardioversion for a client with supraventricular tachycardia. Which action by the primary nurse would cause the charge nurse to intervene? 1. Administers a one-time dose of IV midazolam 2. Disengages the “sync” function on the defibrillator 3. Places defibrillator pads on upper right and lower left chest 4. Turns off the client’s oxygen and moves it away from the bed

2. Disengages the “sync” function on the defibrillator

The nurse is providing discharge teaching to a client with a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which food? SATA 1. Bananas 2. Broccoli 3. Liver 4. Oranges 5. Spinach

2. Broccoli 3. Liver 5. Spinach

The nurse is planning care for a child being admitted with Kawasaki disease and should give priority to which nursing intervention? 1. Apply cool compresses to the skin of the hands and feet 2. Monitor for a gallop heart rhythm and decreased urine output 3. Prepare a quiet, non-stimulating, and restful environment 4. Provide soft foods and liberal amounts of clear liquid

2. Monitor for a gallop heart rhythm and decreased urine output

A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention? SATA 1. Blood pressure of 90/70 mm Hg 2. Bounding peripheral pulses 3. Decreased breath sounds on left side 4. Distant heart tones 5. Jugular venous distention

1. Blood pressure of 90/70 mm Hg 4. Distant heart tones 5. Jugular venous distention

The home health nurse visits a client with atrial fibrillation who is newly prescribed digoxin 0.25 mg orally on even-numbered days. Which of the following client statements show that teaching has been effective? SATA 1. I need to call the health care provider (HCP) if I have trouble reading 2. I need to check my blood pressure before taking my medicine 3. I should call the HCP if I develop nausea and vomiting 4. I should check my heart rate prior to taking this medication 5. I will call the HCP if I feel dizzy and lightheaded

1. I need to call the health care provider (HCP) if I have trouble reading 3. I should call the HCP if I develop nausea and vomiting 4. I should check my heart rate prior to taking this medication 5. I will call the HCP if I feel dizzy and lightheaded

The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown in the exhibit. Which medications due at this time are safe to administer? SATA Temperature 98.4F Blood pressure 124/78 mm Hg Heart rate 46/min and irregularly irregular Respirations 22/min 1. Diltiazem extended-release PO 2. Heparin subcutaneous injection 3. Lisinopril PO 4. Metoprolol PO 5. Timolol ophthalmic

2. Heparin subcutaneous injection 3. Lisinopril PO

A nurse receives an electrocardiogram of a client with type 2 diabetes, heart failure, and hypothyroidism. Based on the findings, which of the following medications should the nurse suspect as the most likely cause? 1. Captopril 2. Carvedilol 3. Glimepiride 4. Levothyroxine

2. Carvedilol

A client with hypertension is prescribed lisinopril. The nurse instructs the client to notify the health care provider immediately if which adverse effect occurs when taking this medication? 1. Cough 2. Dizziness 3. Rapid-onset confusion 4. Swelling of the lips and tongue

4. Swelling of the lips and tongue

The nurse is caring for a client with cardiomyopathy and coronary artery disease. The client is reporting increasing chest pain and has bilateral lung crackles on auscultation. The health care provider has written several new prescriptions. Which new prescription should the nurse clarify? SATA Blood pressure 84/58 mm Hg Heart rate 108/min Respirations 28/min Oxygen saturation 90% 1. Administer 2,000 mL normal saline bolus 2. Administer IV nitroglycerin 3. Apply 4 L oxygen by nasal cannula 4. Obtain a STAT 12-lead ECG 5. Obtain blood for cardiac enzyme testing

1. Administer 2,000 mL normal saline bolus 2. Administer IV nitroglycerin

The nurse is providing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptoms should be immediately reported to the health care provider? 1. Fever 2. Irritability 3. Knee pain 4. Skin peeling

1. Fever

An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately? 1. Is there anything I can take for my dry, hacking cough? 2. My blood pressure this morning was 158/84 mm Hg. 3. Sometimes I feel dizzy when I stand up. 4. Will you look at my tongue? It feels thicker than normal.

4. Will you look at my tongue? It feels thicker than normal.

A client with long-term hypertension and hypercholesterolemia comes to the clinic for an annual checkup. The client takes nifedipine, simvastatin, and spironolactone and reports some occasional dizziness. Which statement by the client would warrant intervention by the nurse? 1. I’ve been better about walking for 20 minutes 3 days a week on my treadmill. 2. I’ve been trying to eat more fruits and vegetables. I discovered that I really like grapefruit. 3. I’ve heard that having a glass of red wine with dinner every night is good for my heart. 4. We no longer add salt when preparing meals. It has really been hard to get used to that.

2. I’ve been trying to eat more fruits and vegetables. I discovered that I really like grapefruit.

A client with coronary artery disease and atrial fibrillation is being discharged home following coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse identifies which educational topic as the highest priority for this client? Aspirin | Clopidogrel | Rivaroxaban | Metoprolol | Rosuvastatin | Lisinopril 1. Bleeding risk 2. Bronchospasm 3. Muscle injury 4. Tinnitus

1. Bleeding risk

Which prescriptions for these clients does the nurse question? SATA 1. Client with clostridium difficile colitis, prescribed vancomycin 125 mg PO 2. Client with diabetes and elevated mealtime glucose, prescribed lispro insulin scale 6 units subcutaneously 3. Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous 4. Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO 5. Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO

4. Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO 5. Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO

A client is 6 hours postoperative from hip surgery after receiving regional anesthesia and has epidural continuous anesthesia in place. Which is the most important reason for the nurse to contact the health care provider? 1. Client reports paresthesia bilaterally since the surgery 2. Fondaparinux is prescribed for STAT administration 3. Lower-extremity muscle strength is 3⁄5 bilaterally 4. Postoperative laboratory results show hemoglobin of 909 g/dL

2. Fondaparinux is prescribed for STAT administration

A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin (NTG) to treat angina. Which statement by the client indicates that further teaching is required? 1. I may experience flushing but will continue to take the medication as prescribed 2. I should lie down before taking the medication 3. I should not swallow the tablet 4. I will wait to call 911 if I don’t experience relief after the third tablet.

4. I will wait to call 911 if I don’t experience relief after the third tablet.

The nurse elevates morning laboratory results for several clients who were admitted 24 hours earlier. Which laboratory report requires priority follow-up? 1. Client with chronic obstructive pulmonary disease who has a PaCO2 of 52 mm Hg 2. Client with heart failure who has a brain natriuretic peptide level of 800 pg/mL 3. Client with infected pressure ulcer who has a white blood cell count of 13,000/mm3 4. Client with pulmonary embolism who has a partial thromboplastin time of 127 seconds

4. Client with pulmonary embolism who has a partial thromboplastin time of 127 seconds

The nurse is performing a cardiac assessment on a client. The nurse auscultates a loud blowing sound at the second intercostal space, right sternal border. How should the nurse document this finding? 1. Arterial bruit 2. Murmur heard at the aortic area 3. Pericardial friction rub 4. S3 gallop heard at the mitral area

2. Murmur heard at the aortic area

The nurse is preparing medications for a group of clients. Which prescription should the nurse clarify with the health care provider before administering? 1. Client diagnosed with cirrhosis had 2 stools today; laxative lactulose prescribed daily 2. Client is prescribed lisinopril PO daily; serum potassium level is 5.6 mEq/L 3. Client is receiving vancomycin IV; mild facial flushing noted after 30 minutes 4. Client with diabetes has insulin glargine prescribed; current blood glucose is 100 mg/dL

2. Client is prescribed lisinopril PO daily; serum potassium level is 5.6 mEq/L

A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? SATA 1. I don’t plan on eating any more frozen meals 2. I plan to take my diuretic pill in the morning 3. I will weigh myself at least every other day 4. I’m going to look into joining a cardiac rehabilitation program 5. Ibuprofen works best for me when I have pain

3. I will weigh myself at least every other day 5. Ibuprofen works best for me when I have pain

The nurse is preparing to administer medications after assessing a client with a myocardial infarction. Based on the collected data, which of the following prescribed medications are appropriate for the nurse to administer? SATA Temperature 98.4F Blood pressure 126/81 mm Hg Heart rate 49/min Respirations 16/min Hematocrit 40% Hemoglobin 14.0 g/dL Platelets 200,000.mm3 Potassium 4.0 mEq/L HDL cholesterol 21 mg/dL LDL cholesterol 200 mg/dL 1. Aspirin 2. Atorvastatin 3. Docusate sodium 4. Lisinopri 5. Metoprolol

1. Aspirin 2. Atorvastatin 3. Docusate sodium 4. Lisinopri

The emergency nurse is admitting a 12 year old client who reports palpitations. Which action should the nurse anticipate? Temperature 97.1F Blood pressure 114/74 mm Hg Heart rate 234/min Respirations 24/min spO2 97% 1. Administering epinephrine by rapid IV push 2. Assisting the client to a tripod position 3. Instructing the client to hold their breath and bear down 4. Sedating the client for immediate asynchronous defibrillation

3. Instructing the client to hold their breath and bear down

Which subjective or objective assessment finding would the nurse expect to find in a client with severe aortic stenosis? 1. Bounding peripheral pulses 2. Diastolic murmur 3. Loud second heart sound 4. Syncope on exertion

4. Syncope on exertion

A client in the emergency department has an acute myocardial infarction. The health care provider (HCP) has prescribed thrombolytic therapy. Which assessment data should the nurse report immediately to the HCP? 1. Client has a history of cerebral arteriovenous malformation 2. Client is currently menstruating 3. Client rates chest pain as 8 on a scale of 0-10 4. Current blood pressure is 170/92 mm Hg

1. Client has a history of cerebral arteriovenous malformation

The nurse is assessing a 70-year-old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department. Which hospital protocol would be the most appropriate to follow initially? 1. Food poisoning 2. Influenza 3. Myocardial infarction 4. Stroke

3. Myocardial infarction

The nurse is monitoring a client who has been on clopidogrel therapy. Which assessments are essential? SATA 1. Assess for bruising 2. Assess for tarry stools 3. Monitor intake and output 4. Monitor liver function tests 5. Monitor platelets

1. Assess for bruising 2. Assess for tarry stools 5. Monitor platelets

The nurse is reviewing laboratory data of a client who is receiving warfarin therapy for atrial fibrillation. Today’s INR is 5.0. Which action should the nurse take? 1. Administer the next scheduled dose of warfarin 2. Anticipate infusing fresh, frozen plasma 3. Call the pharmacy to see if protamine is available 4. Request a prescription from the health care provider (HCP) for vitamin K

4. Request a prescription from the health care provider (HCP) for vitamin K

The nurse provides instructions to a client discharged on warfarin, after being treated for a pulmonary embolism (PE) following surgery. Which statements made by the client indicate the need for further teaching? SATA 1. I will need to take my blood thinner for about 3-6 months 2. I will place small rugs on my wood floors to cushion a fall 3. I will take a baby aspirin if I have mild chest pain 4. I will use a soft-bristled toothbrush to clean my teeth 5. I will wear a blood thinner MedicAlert tag

2. I will place small rugs on my wood floors to cushion a fall 3. I will take a baby aspirin if I have mild chest pain

The clinic nurse is reviewing telephone messages from four clients. Which client’s call should the nurse return first? 1. Client who has just taken albuterol and reports a heart rate of 108/min and a coarse tremor in both arms 2. Client who is prescribed azithromycin and reports frequent, foul-smelling, liquid stools and abdominal cramping 3. Client who is prescribed metformin and reports a blood glucose of 284 mg/dL and frequent urination 4. Client who takes amiodarone and reports a dry cough and increased dyspnea when walking around the house

4. Client who takes amiodarone and reports a dry cough and increased dyspnea when walking around the house

An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently? 1. Apical heart rate is 62/min 2. Blood sugar is 240 mg/dL 3. Client is taking 20 mg fluoxetine daily 4. Serum creatinine is 2.3 mg/dL

4. Serum creatinine is 2.3 mg/dL

A nurse in the cardiac intermediate care unit is caring for a client with acute decompensated heart failure (ADHF). The client also has a history of coronary artery disease and peripheral vascular disease. The nurse is preparing to administer medications. Based on the assessment data, the nurse should question which medication? Blood pressure 110/60 mm Hg Pulse 80/min Respirations 22/min Oxygen saturation 90% on room air Crackles in middle & lower lung fields Moderate jugular venous distention 3+ pedal edema 1. Aspirin 2. Atorvastatin 3. Furosemide 4. Metoprolol

4. Metoprolol

The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving a first dose of propranolol. Which assessment is most concerning to the nurse? 1. Client reports a headache 2. Current blood pressure is 160/88 mm Hg 3. Heart rate has dropped from 70/min to 60/min 4. Slight wheezes auscultated during inspiration

4. Slight wheezes auscultated during inspiration

The nurse has received report on 4 pediatric clients on a telemetry unit. Which client should the nurse assess first? 1. Adolescent client with coarctation of the aorta and diminished femoral pulses 2. Infant client with ventricular septal defect with reported grunting during feeding 3. Newborn client with patent ductus arteriosus and a loud machinery-like systolic murmur 4. Preschool client with tetralogy of Fallot who has finger clubbing and irritability

2. Infant client with ventricular septal defect with reported grunting during feeding

The nurse is assessing for the presence of jugular venous distention (JVD) on a newly admitted client with a history of heart failure. Which is the best position for the nurse to place the client in when observing for JVD? 1. Head of the bed elevated to a 45-degree angle 2. Head of the bed elevated to a 60-degree angle 4. Client who takes amiodarone and reports a dry cough and increased dyspnea when walking around the house 25 3. Head of the bed elevated to a 90-degree angle 4. Head of the bed flat

1. Head of the bed elevated to a 45-degree angle

A client with uncontrolled hypertension is prescribed clonidine. What instruction is most important for the clinic nurse to give this client? 1. Avoid consuming high-sodium foods 2. Change positions slowly to prevent dizziness 3. Don’t stop taking this medication abruptly 4. Use an oral moisturizer to relieve dry mouth

3. Don’t stop taking this medication abruptly

The health care provider prescribes simvastatin for a client with hyperlipidemia. The nurse instructs the client to take this medication in which manner? 1. At noon with a meal 2. In the morning on an empty stomach 3. In the morning with breakfast 4. With the evening meal

4. With the evening meal

A nurse caring for a client with a central venous catheter (CVC) enters the client’s room and notes that the CVC is dislodged and lying in the client’s bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? SATA 1. Administers oxygen via non-rebreather mask 2. Apply an occlusive dressing over the insertion site 3. Assist the client to high Fowler position 4. Monitor vital signs and respiratory effort 5. Notify the health care provider

1. Administers oxygen via non-rebreather mask 2. Apply an occlusive dressing over the insertion site 4. Monitor vital signs and respiratory effort 5. Notify the health care provider

1. Crackles in lungs 4. Jugular venous distention 5. Pedal edema

The nurse is providing community health screening. Which of the following clients should be referred to a health care provider for further evaluation? 1. 30-year-old athlete with a heart rate of 50/min 2. 45-year-old client with a body mass index of 35 kg/m2 and fingerstick glucose of 150 mg/dL 3. 55-year-old client missing all the hair on the lower legs and failing the pinprick test 4. 80-year-old client with a blood pressure of 150/90 mm Hg

3. 55-year-old client missing all the hair on the lower legs and failing the pinprick test

A client is started on lisinopril therapy. Which assessment finding requires immediate action? 1. Blood pressure 129/80 mm Hg 2. Heart rate 100/min 3. Serum creatinine 2.5 mg/dL 4. Serum potassium 3.5 mEq/dL

3. Serum creatinine 2.5 mg/dL

A client with heart failure is started on furosemide. The laboratory results are shown in the exhibit. The nurse is most concerned about which condition? Sodium 134 Potassium 3.4 chloride 108 Magnesium 0.9 1. Atrial fibrillation 2. Atrial flutter 3. Mobitz 2 4. Torsades de pointes

4. Torsades de pointes

The nurse is caring for a client who has been admitted to the hospital for an acute exacerbation of heart failure. Blood pressure is 104/62 mm Hg, pulse is 96/min, respirations are 22/min, and oxygen saturation is 91%. Which of these findings supports the diagnosis of acute heart failure exacerbation? 1. B-type natriuretic peptide (BNP) 1382 pg/mL 2. Flat jugular veins when seated at a 45-degree angle 3. Sodium 150 mEq/L 4. Urine output greater than 100 mL/hr

1. B-type natriuretic peptide (BNP) 1382 pg/mL

A nurse is assessing a 1-month old infant with an atrial septal defect (ASD). which assessment finding does the nurse expect? 1. Muffled heart tones 2. Murmur 3. Cyanosis 4. Weak femoral pulses

2. Murmur

A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client’s symptoms? SATA 1. Atorvastatin 2. Metformin 3. Metoprolol 4. Olanzapine 5. Omeprazole

3. Metoprolol 4. Olanzapine

A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication? SATA 1. Blood pressure of 140/84 mm Hg 2. Heart rate of 98/min 3. Platelet count of 200,000/mm3 4. Report of Ginkgo biloba use 5. Report of peptic ulcer disease

4. Report of Ginkgo biloba use 5. Report of peptic ulcer disease

A client is being discharged with a prescription for apixaban after being treated for a pulmonary embolus. Which clinical data is most concerning to the nurse? 1. Client eats a vegetarian diet 2. Client has chronic atrial fibrillation 3. Client takes indomethacin for osteoarthritis 4. Client’s platelet count is 176x10^3/mm3

3. Client takes indomethacin for osteoarthritis

The home health nurse is visiting an infant who recently had surgery to repair tetralogy of Fallot. Which of the following signs of heart failure should the nurse teach the parents to report to the health care provider? SATA 1. Cool extremities 2. Increase in appetite 3. Puffiness around the eyes 4. Reduction in number of wet diapers 5. Weight gain

1. Cool extremities 3. Puffiness around the eyes 4. Reduction in number of wet diapers 5. Weight gain

A 45-year-old client with atrial fibrillation has been prescribed diltiazem. Which client outcome would best indicate that the medication has had its intended effect? 1. Atrial fibrillation is converted to sinus rhythm 2. Blood pressure is 126/78 mm Hg 3. No signs or symptoms of stroke 4. Ventricular rate decreased from 158/min to 88/min

4. Ventricular rate decreased from 158/min to 88/min

The nurse reports to a call for help from another staff member. Upon entering the client’s room, the nurse observes an unlicensed assistive personnel (UAP) performing chest compressions on an unconscious adult client while another nurse is calling for the emergency response team. What action by the arriving nurse is the priority? 1. Ask the UAP to stop compressions and check for a pulse 2. Establish additional IV access with large-bore IVs 3. Obtain the defibrillator and apply the pads to the client’s chest 4. Prepare to administer 100% O2 with a bag valve mask

3. Obtain the defibrillator and apply the pads to the client’s chest

The nurse is caring for a newborn with patent ductus arteriosus. Which assessment finding should the nurse expect? 1. Harsh systolic murmur 2. Loud machine-like murmur 3. Soft diastolic murmur 4. Systolic ejection murmur

2. Loud machine-like murmur

A client with stable angina is being discharged home with a prescription for a transdermal nitroglycerin patch. The nurse has reviewed discharge instructions on the medication with the client. Which statement by the client indicates that teaching has been effective? 1. I can continue to take my prescription of sildenafil 2. I should take the patch off when I shower 3. I will remove the patch if I develop a headache 4. I will rotate the site where I apply the patch

4. I will rotate the site where I apply the patch

The nurse admits a client with newly diagnosed unstable angina. Which information obtained during the admission health history is most important for the nurse to report to the health care provider (HCP) immediately? 1. Drinks 6 cans of beers on the weekend 2. Gets up 4 times during the night to void 3. Smokes 1 pack of cigarettes daily 4. Uses sildenafil occasionally

4. Uses sildenafil occasionally

A client with chronic stable angina is reporting chest pain. The nurse notices that the transdermal nitroglycerin patch that was applied 1 hour ago has peeled off. The client’s vital signs are stable. What is the nurse’s priority action? Aspirin tablet Metoprolol Nitroglycerin patch Morphine sulfate Nitroglycerin tablets 1. Administer PRN morphine 2. Administer PRN sublingual nitroglycerin 3. Apply a new transdermal nitroglycerin patch 4. Obtain a 12-lead electrocardiogram

2. Administer PRN sublingual nitroglycerin

The nurse is assigned to the following clients. Which client does the nurse assess/identify as being at greatest risk for the development of a deep venous thrombosis (DVT)? 1. A 25-year-old client with abdominal pain who smokes cigarettes and takes oral contraceptives 2. A 55-year-old ambulatory client with exacerbation of chronic bronchitis and hematocrit of 56% 3. A 72-year-old client with a fever who is 2 days post coronary stent placement 4. An 80-year-old client who is 4 days postoperative from repair of a fractured hip

4. An 80-year-old client who is 4 days postoperative from repair of a fractured hip

A 3-month-old who weighs 8.8 lb (4 kg) has just returned to the intensive care unit after surgical repair of a congenital heart defect. Which finding by the nurse should be reported immediately to the health care provider? 1. Chest tube output of 50 mL in the past hour 2. Heart rate of 150/min 4. 3. Temperature of 97.5F Urine output of 8 mL in the past hour

1. Chest tube output of 50 mL in the past hour

The nurse is caring for a client with chronic, stable angina. The client takes the long-acting nitrate isosorbide mononitrate. Which client outcome indicates that the drug is effective? 1. Client is able to shower, dress, and fix hair without any chest pain 2. Client reports a reduction in stress level and anxiety 3. Client reports being able to sleep through the night 4. Client’s blood pressure is 128/78 mm Hg and heart rate is 82/min

1. Client is able to shower, dress, and fix hair without any chest pain

A client with a history of heart failure calls the clinic and reports a 3-lb weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client’s medications and anticipates the immediate need for dosage adjustment of which medication? 1. Bumetanide 2. Candesartan 3. Carvedilol 4. Isosobide

1. Bumetanide

When monitoring an infant with a left-to-right-sided heart shunt, which findings would the nurse expect during the physical assessment? SATA 1. Clubbing of the fingertips 2. Cyanosis when crying 3. Diaphoresis during feedings 4. Heart murmur 5. Poor weight gain

3. Diaphoresis during feedings 4. Heart murmur 5. Poor weight gain

The nurse prepares to administer 9:00 AM medications to a client. Which data should the nurse evaluate prior to administration? SATA Aspirin Metoprolol Quinapril 1. Blood pressure 2. Blood sugar 3. Heart rate 4. International Normalized Ratio 5. Potassium level

1. Blood pressure 3. Heart rate 5. Potassium level

An 8-month-old infant is scheduled for a femorally inserted balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding should the nurse report to the health care provider that could possibly delay the procedure? 1. Auscultation of a loud heart murmur 2. Infant has been NPO for 4 hours 3. Infant has severe diaper rash 4. Slight cyanosis of the nail beds

3. Infant has severe diaper rash

A client is admitted to the cardiac care unit with atrial fibrillation. Vital signs are shown in the exhibit. Which prescription should the nurse perform first? Temperature 98.2F Blood pressure 120/80 mmHg Heart rate 140/min, irregular Respirations 18/min SpO2 98% 1. Administer diltiazem 20 mg IVP 2. Administer rivaroxaban 20 mg PO 3. Draw blood for a thyroid function test 4. Send the client for echocardiogram

1. Administer diltiazem 20 mg IVP

The home health nurse visits a client with hypertension whose blood pressure has been well controlled on oral valsartan 320 mg daily. The client’s blood pressure is 190/88 mm Hg, significantly higher than it was 2 weeks ago. The client reports a cold, a stuffy nose, and sneezing for 3 days. Which question is most appropriate for the nurse to ask? 1. Are you taking any over-the-counter medications for your cold? 2. Are you taking extra vitamin C? 3. Did you babysit your granddaughter this past week? 4. Did you get a flu shot in the past week?

1. Are you taking any over-the-counter medications for your cold?

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment would require immediate follow-up? 1. Abdomen is soft, nondistended, and tender to touch 2. Blood pressure is 96/66 mm Hg and apical pulse is 112/min 3. Client rates pain as 4 on a scale of 0-10 4. Green bile is draining from the nasogastric tube

2. Blood pressure is 96/66 mm Hg and apical pulse is 112/min

The nurse is reviewing the medication administration record of a client with atrial fibrillation. Which of the following should the nurse monitor before giving these medications? SATA Prednisone Metoprolol Digoxin Enoxaparin 1. Digoxin level 2. Glucose 3. INR 4. Platelet count 5. Serum potassium

1. Digoxin level 2. Glucose 4. Platelet count 5. Serum potassium

The health care provider has prescribed spironolactone to be given in addition to hydrochlorothiazide to a client with hypertension. Which finding by the nurse indicates that the spironolactone is having the desired effect? 1. Blood glucose of 95 mg/dL 2. Potassium level of 4.2 mEq/L 3. Reduction in dizziness 4. Sodium level of 138 mEq/L

2. Potassium level of 4.2 mEq/L

The nurse assesses these symptoms in a client with bacterial pneumonia: chills, elevated temperature, tachypnea,productive cough of yellow sputum, shortness of breath, and fatigue. Based on the assessment data, what is the most appropriate nursing diagnosis (ND) for this client? 1. Impaired gas exchange 2. Impaired spontaneous ventilation 3. Ineffective breathing pattern 4. Risk for infection

1. Impaired gas exchange

A nurse receives report on a group of clients. Which client should the nurse assess first? 1. A preschool-age child with a harsh cough, expiratory wheezes, and mild intercostal retractions 2. A toddler playing with small toys who appears in distress, has circumoral cyanosis, and cannot speak 3. A toddler with a barking cough, infrequent inspiratory stridor, and oxygen saturation of 94% on room air 4. An infant with an axillary temperature of 100.1 F (37.8 C) who is tugging at the left ear

2. A toddler playing with small toys who appears in distress, has circumoral cyanosis, and cannot speak

A client has an allergy skin test that is positive for dust mites. The nurse provides instruction on environmental interventions the client can use to control symptoms by reducing exposure to this allergen. Which intervention would be described in this teaching? 1. Allergy shots or sublingual immunotherapy 2. Antihistamine use 3. Vacuum carpeting once a week 4. Wash bed linens in hot water once a week

4. Wash bed linens in hot water once a week

\*\*The nurse is caring for a client who has been receiving mechanical ventilation (MV) for 4 days. During multidisciplinary morning rounds, the health care provider questions the development of a ventilator-associated pneumonia (VAP). Which of the following manifestations does the nurse assess as the best indicator of VAP? 1. Blood-tinged sputum 2. Positive blood cultures 3. Positive, purulent sputum culture 4. Rhonchi and crackles

3. Positive, purulent sputum culture

Which pediatric respiratory presentation in the emergency department is a priority for nursing care? 1. Client with an acute asthma exacerbation but no wheezing 2. Client with bronchiolitis with low-grade fever and wheezing 3. Client with runny nose with seal-like barking cough 4. Cystic fibrosis client with fever and yellow sputum

1. Client with an acute asthma exacerbation but no wheezing

A client presents to the emergency department with a stab wound to the chest. The nurse assesses tachycardia,tachypnea, and a sucking sound coming from the wound. Which of the following actions is priority? 1. Administer prescribed IV fluids 2. Apply supplemental oxygen via nonrebreather mask 3. Assist the health care provider to prepare for chest tube insertion 4. Cover the wound with petroleum gauze taped on three sides

4. Cover the wound with petroleum gauze taped on three sides

The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, "I can't breathe." The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time? 1. Administer albuterol nebulizer 2. Assist the client in identifying the trigger and ways to avoid it 3. Coach the client through controlled breathing exercises 4. Continue to monitor oxygen saturation

3. Coach the client through controlled breathing exercises

The nurse is gathering data on a client with obstructive sleep apnea. Which findings are consistent with this client's diagnosis? Select all that apply. 1. Difficulty arousing from sleep 2. Excessive daytime sleepiness 3. Morning headaches 4. Postural collapse and falling 5. Snoring during sleep 6. Witnessed episodes of apnea

2. Excessive daytime sleepiness 3. Morning headaches 5. Snoring during sleep 6. Witnessed episodes of apnea

The emergency nurse admits a semiconscious client with periorbital bruising and severe tongue edema after alaceration sustained in an unwitnessed tonic-clonic seizure. The health care provider prescribes a nasopharyngeal airway to maintain airway patency. Which initial action by the nurse is appropriate? 1. Contact the health care provider and clarify the prescription 2. Ensure correct placement after insertion by auscultating the lungs 3. Select an appropriate size by measuring from nose tip to earlobe 4. Verify that the client has no history of bleeding disorders or aspirin use

1. Contact the health care provider and clarify the prescription

A client with a severe asthma exacerbation following influenza infection is transferred to the intensive care unit due to rapidly deteriorating respiratory status. Which clinical manifestations support the nurse's assessment of impending respiratory failure? Select all that apply. 1. Arterial pH 7.50 2. PaCO2 55 mm Hg (7.3 kPa) 3. PaO2 58 mm Hg (7.7 kPa) 4. Paradoxical breathing 5. Restlessness and drowsiness

2. PaCO2 55 mm Hg (7.3 kPa) 3. PaO2 58 mm Hg (7.7 kPa) 4. Paradoxical breathing 5. Restlessness and drowsiness

**Exhibit:** Preoperative 15 g/dL (150 g/L) Postop day 1: 12.5g/dL (125 g/L) chest drainage output 400 mL/24 hr Postop day 2: 13 g/ dL (130 g/L) chest drainage output 50 mL/12 hr A client had a thoracotomy 2 days ago to remove a lung mass and has a right chest tube attached to negative suction.Immediately after turning the client to the left side to assess the lungs, the nurse observes a rush of approximately 125mL of dark bloody drainage into the drainage tubing and collection chamber. What is the appropriate nursing action? (exhibit) Click on the exhibit button for additional information. 1. Document and continue to monitor chest drainage 2. Immediately clamp the chest tube 3. Notify the health care provider 4. Request repeat hematocrit and hemoglobin levels

1. Document and continue to monitor chest drainage

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment? 1. Color of sputum 2. Lung sounds 3. Saturation level 4. White blood cell count (WBC)

4. White blood cell count (WBC)

The hospice nurse is caring for an actively dying client who is unresponsive and has developed a loud rattling sound with breathing ("death rattle") that distresses family members. Which prescription would be most appropriate to treat this symptom? 1. Atropine sublingual drops 2. Lorazepam sublingual tablet 3. Morphine sublingual liquid 4. Ondansetron sublingual tablet

1. Atropine sublingual drops

The nurse is assisting the health care provider (HCP) with a client's chest tube removal. Just as the HCP prepares to pull the chest tube, what instructions should the nurse give the client? 1. "Breathe as you normally would." 2. "Inhale and exhale slowly." 3. "Take a breath in, hold it, and bear down." 4. "Take rapid shallow breaths, similar to panting."

3. "Take a breath in, hold it, and bear down."

A mother reports to the pediatric nurse that her 3-year-old child coughs at night and at times until he vomits. The symptoms have not improved over the past 2 months despite multiple over-the-counter cough medications. What should the nurse explore related to a possible etiology? 1. Ask about exposure to triggers such as pet dander 2. Assess for the presence of a butterfly rash 3. History of intolerance to wheat food products 4. Palpate for an abdominal mass from pyloric stenosis

1. Ask about exposure to triggers such as pet dander

The nurse is preparing medication for 4 clients on a respiratory medical-surgical unit. Which situation would prompt the nurse to clarify the prescribed treatment with the health care provider? 1. Client with bronchospasm who is due to receive nebulized acetylcysteine 2. Client with chronic obstructive pulmonary disease due to receive PO prednisone 3. Client with cystic fibrosis who is due to receive PO pancrelipase with breakfast 4. Client with suspected bacterial pneumonia due to receive IV levofloxacin

1. Client with bronchospasm who is due to receive nebulized acetylcysteine

A nurse is completing discharge teaching to the parent of a child who is postoperative following a tonsillectomy. Which finding should be reported as a priority? 1. Ear pain 2. Frequent swallowing 3. Low-grade fever 4. Objectionable mouth odor

2. Frequent swallowing

The medical surgical nurse cares for a client who had a mediastinal tumor removed 2 days ago and reports difficulty breathing. The client becomes confused and restless, and respirations are 30/min. What is the nurse's next action? 1. Administer a dose of prescribed prn anti-anxiety medication 2. Call the health care provider who performed the surgery 3. Call the rapid response team 4. Place the client in the left lateral recovery position

3. Call the rapid response team

**Exhibit** Discharge medications Albuterol: 2 puffs every 4-6 hours as needed Prednisone: 40 mg PO daily Naproxen: 220 mg PO twice daily Tiotropium: 1 capsule inhaled daily A client with a history of degenerative arthritis is being discharged home following an exacerbation of chronic obstructive pulmonary disease. After reviewing the discharge medications, the nurse should educate the client about which topics? Select all that apply. Click on the exhibit button for additional information. 1. Dryness of the mouth and throat may occur 2. Ringing in the ears is an expected, transient side effect 3. The albuterol canister should not be shaken before use 4. The health care provider should be notified if stools are black and tarry 5. Tiotropium capsules should not be swallowed

1. Dryness of the mouth and throat may occur 4. The health care provider should be notified if stools are black and tarry 5. Tiotropium capsules should not be swallowed

A2-year-old child is brought to the emergency department for a severe sore throat and fever of 102.9 F (39.4 C). The nurse notes that the child is drooling with distressed respirations and inspiratory stridor. What action should the nurse take first? 1. Assess an accurate temperature with a rectal thermometer 2. Directly examine the throat for the presence of exudates 3. Obtain intravenous access for anticipated sterol administration 4. Position the child in tripod position on the parent's lap

4. Position the child in tripod position on the parent's lap

The nurse is caring for a client with asthma exacerbation. Blood pressure is 146/86 mm Hg, pulse is 110/min, and respirations are 32/min. The respiratory therapist administers nebulized albuterol as prescribed. One hour after the treatment, the nurse assesses which finding that indicates the drug is producing the therapeutic effect? 1. Constricted pupils 2. Heart rate of 120/min 3. Respirations of 24/min 4. Tremor

3. Respirations of 24/min

The nurse is assessing a client diagnosed with tuberculosis who started taking rifapentine a week ago. Which statement by the client warrants further assessment and intervention by the nurse? 1. "I do not want to get pregnant, so I restarted my oral contraceptive last month." 2. "I have been taking my medications with breakfast every morning." 3. "I should alert my health care provider if I notice yellowing of my skin." 4. "Since I started this medicine, my saliva has become a red-orange color."

1. "I do not want to get pregnant, so I restarted my oral contraceptive last month."

The nurse has provided teaching about home care to the parent of a 10-year-old with cystic fibrosis. Which of the following statements by the parent indicates that teaching has been effective? Select all that apply. 1 "Chest physiotherapy is administered only if respiratory symptoms worsen." 2. "I will give my child pancreatic enzymes with all meals and snacks." 3. "I will increase my child's salt intake during hot weather." 4. "Our child will need a high-carbohydrate, high-protein diet. " 5. "We will limit our child's participation in sports activities."

2. "I will give my child pancreatic enzymes with all meals and snacks." 3. "I will increase my child's salt intake during hot weather." 4. "Our child will need a high-carbohydrate, high-protein diet. "

The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident. The drainage has been consistently 25-50 mL/hr for the majority of the shift. However, over the past 2 hours there has been no drainage. Which actions should the nurse take? Select all that apply. 1. Auscultate breath sounds 2. Increase amount of suction 3. Instruct client to cough and deep breathe 4. Milk the chest tube 5. Reposition the client

1. Auscultate breath sounds 3. Instruct client to cough and deep breathe 5. Reposition the client

**Exhibit** Vital signs: Heart rate: 132/min Respirations: 40/min Oz saturation or SpO2: 80% The nurse is caring for a client receiving mechanical ventilation via tracheostomy 2 weeks following a tracheotomy. The nurse enters the client's room to address a ventilator alarm and notes the tracheostomy tube dislodged and lying on the client's chest. Which action by the nurse is appropriate? Click on the exhibit button for additional information. 1. Apply a nonrebreather face mask with 100% oxygen 2. Apply dry, sterile gauze over the stoma and secure with tape 3. Insert a new tracheostomy tube using the bedside obturator 4. Insert a sterile catheter into the stoma and suction the airway

3. Insert a new tracheostomy tube using the bedside obturator

The nurse is caring for a 4-year-old client with cystic fibrosis who uses a high-frequency chest wall oscillation (HFCWO) vest for chest physiotherapy. After reinforcing education with the client's parents, which statement by a parent requires further teaching? 1. "I will allow my child to have a snack while using the HFCWO vest to encourage cooperation." 2. "I will give my child the nebulized bronchodilator treatment during therapy with the HFCWO vest." 3. "I will perform manual chest percussion on my child if the HFCWO vest is broken or unavailable." 4. "My child will use the HFCWO vest once in the morning, once in the evening, and as

1. "I will allow my child to have a snack while using the HFCWO vest to encourage cooperation."

A nurse has received new medication prescriptions for a client admitted with hypertension and an exacerbation of chronic obstructive pulmonary disease. Which prescription should the nurse question? 1. Amlodipine 2. Codeine 3. Ipratropium 4. Methylprednisolone

2. Codeine

In the emergency department, a pediatric client is placed on mechanical ventilation by means of an endotracheal tube. Several hours later, the nurse enters the room and finds the client in respiratory distress. It is most important for the nurse to take which of these actions? 1. Assess the client for intercostal retractions 2. Assess the client's blood pressure in both arms 3. Auscultate the client's lung sounds 4. Observe the color of the client's fingernail beds

3. Auscultate the client's lung sounds

\*\*The nurse provides discharge instructions to a 67-year-old client with chronic bronchitis who was hospitalized for community-acquired pneumonia. Which instructions should be included in the discharge teaching plan? Select all that apply. 1. "Avoid the use of over-the-counter cough suppressant medicines." 2. "Oral antibiotics are not needed at home as you had intravenous (IV) therapy in the hospital." 3. "Pneumonia vaccination is not needed as you now have lifelong immunity." 4. "Schedule a follow-up with the health care provider (HCP) and chest x-ray." 5. "Use a cool mist humidifier in your bedroom at night." 6. "Use the incentive spirometer at home."

1. "Avoid the use of over-the-counter cough suppressant medicines." 4. "Schedule a follow-up with the health care provider (HCP) and chest x-ray." 5. "Use a cool mist humidifier in your bedroom at night." 6. "Use the incentive spirometer at home."

The community health nurse prepares a teaching plan for a client with latent tuberculosis who is prescribed oral isoniazid (INH). Which instructions should the nurse include? Select all that apply. 1. Avoid drinking alcohol 2. Expect body fluids to change color to red 3. Report yellowing of skin or sclera 4. Report numbness and tingling of extremities 5. Take with aluminum hydroxide to prevent gastric irritation

1. Avoid drinking alcohol 3. Report yellowing of skin or sclera 4. Report numbness and tingling of extremities

The nurse caring for a client with emphysema is providing teaching for pursed lip breathing exercises. Which statement by the client indicates effective teaching? 1. "As my breathing improves, my lungs will begin to heal." 2. "Pursed lip breathing will help my airways stay open." 3. "This is a relaxation technique to help with my anxiety." 4. "This will help reduce the fluid buildup in my lungs."

2."Pursed lip breathing will help my airways stay open."

The nurse is evaluating how well a client with chronic obstructive pulmonary disease understands the discharge teaching. Which statements made by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply. 1. "I exhale for 2 seconds through pursed lips." 2. "I exhale for 4 seconds through pursed lips." 3. "I inhale for 2 seconds through my mouth." 4. "I inhale for 2 seconds through my nose, keeping my mouth closed." 5. "I inhale for 4 seconds through my nose, keeping my mouth closed.

2. "I exhale for 4 seconds through pursed lips." 4. "I inhale for 2 seconds through my nose, keeping my mouth closed."

A nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first? 1. Administer prescribed analgesic medication for incisional pain 2. Encourage use of incentive spirometer every 2 hours while awake 3. Offer an additional pillow to splint the incision while coughing 4. Promote increased oral fluid intake

1. Administer prescribed analgesic medication for incisional pain

The client has a chest tube for a pneumothorax. While repositioning the client for an x-ray, the technician steps on the tubing and accidently pulls the chest tube out. The client's oxygen saturation drops and the pulse is 132/min: the nurse hears air leaking from the insertion site. What is the nurse's immediate action? 1. Apply an occlusive sterile dressing secured on 3 sides 2. Apply an occlusive sterile dressing secured on 4 sides 3. Assess lung sounds 4. Notify the health care provider (HCP)

1. Apply an occlusive sterile dressing secured on 3 sides

The nurse receives change of shift report on 4 clients. Which client should the nurse assess first? 1. 6-month-old with respiratory syncytial virus and pulse oximetry of 90% 2. 1-year-old with otitis media and a temperature of 102.5 F (39.2 C) rectally 3. 2-year-old with suspected epiglottitis 4. 3-year-old who has a barking-type cough

3. 2-year-old with suspected epiglottitis

The nurse assesses a client with fever and productive cough for the last 10 days. Which findings support the presence of pneumonia? Select all that apply. 1. Coarse crackles 2. Hyperresonance 3. Pleuritic chest pain 4. Shortness of breath 5. Trachea deviating from midline

1. Coarse crackles 3. Pleuritic chest pain 4. Shortness of breath

The nurse is caring for a client with advanced heart failure on an inpatient hospice unit. The client is having trouble breathing. Which comfort intervention should the nurse implement first? 1. Administer as-needed (prn) albuterol by nebulizer 2. Administer prn intravenous (IV) furosemide 3. Elevate the head of the bed 4. Give prn sublingual morphine

3.Elevate the head of the bed

The nurse reviews discharge instructions with a client who has advanced chronic obstructive pulmonary disease. Which client statement indicates appropriate understanding? Select all that apply. 1"I need to take iron supplements to prevent anemia." 2. "I should report an increase in sputum." 3. "I will eat a low-calorie diet." 4"I will get a pneumococcal vaccine." 5. "I will use albuterol if I am short of breath."

2."I should report an increase in sputum." 4"I will get a pneumococcal vaccine." 5. "I will use albuterol if I am short of breath."

The nurse is teaching an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply. 1. Eating a high-protein snack at bedtime 2. Limiting alcohol intake 3. Losing weight 4. Taking a mild sedative at bedtime 5. Taking modafinil at bedtime 6. Taking a nap during the day

2. Limiting alcohol intake 3. Losing weight

When an unlicensed assistive personnel (UP) assists a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidently falls over and cracks. The UP immediately reports this incident to the nurse. What is the nurse's immediate action? 1. Clamp the tube close to the client's chest until a new chest drainage unit is set up 2. Notify the health care provider (HCP) 3. Place the distal end of the chest tube into a bottle of sterile saline 4. Position the client on the left side

3. Place the distal end of the chest tube into a bottle of sterile saline

The nurse is caring for a child newly diagnosed with cystic fibrosis. Which of the following interventions are appropriate to include in the child's plan of care? Select all that apply. 1. Aerobic exercise 2. Chest physiotherapy 3. Low-calorie diet 4. Oral fluid restriction 5. Social support services

1. Aerobic exercise 2. Chest physiotherapy 5. Social support services

A client is having a severe asthma attack lasting over 4 hours after exposure to animal dander. On arrival, the pulse is 128/min, respirations are 36/min, pulse oximetry is 86% on room air, and the client is using accessory muscles to breathe. Lung sounds are diminished and high-pitched wheezes are present on expiration. Based on this assessment, the nurse anticipates the administration of which of the following medications? Select all that apply. 1. Inhaled albuterol nebulizer every 20 minutes 2. Inhaled ipratropium nebulizer every 20 minutes 3. Intravenous methylprednisolone 4. Montelukast 10 mg by mouth STAT 5. Salmeterol metered-dose inhaler ever 20 minutes

1. Inhaled albuterol nebulizer every 20 minutes 2. Inhaled ipratropium nebulizer every 20 minutes 3. Intravenous methylprednisolone

The nurse is assessing a client an hour after a left lung lobectomy. The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale. Pulse oximetry is 92% on 4 L oxygen via nasal cannula. The chest tube is set to continuous water seal suction at -20 cm HO. The collection chamber has accumulated 320 mL of frank red drainage in the last hour. What is the priority nursing action? 1. Clamp the chest tube immediately 2. Increase oxygen to 6 L via nasal cannula 3. Medicate client for pain and document the findings 4. Notify the health care provider immediately

4. Notify the health care provider immediately

An elderly client with a history of stable chronic obstructive pulmonary disease, alcohol abuse, and cirrhosis has a serum theophylline level of 25.8 mcg/mL (143 mol/L). Which clinical manifestation associated with theophylline toxicity should worry the nurse most? 1. Alterations in color vision 2. Gum (gingival) hypertrophy 3. Hyperthermia 4. Seizure activity

4. Seizure activity

\*\*A client with Alzheimer disease is found slumped over the lunch tray on the bedside table, coughing violently with emesis visible in the back of the throat. The client has a pulse of 135/min, respirations 32/min, and oxygen saturation 84%. The client also has circumoral cyanosis and decreased level of consciousness. Place the nurse's actions while awaiting the arrival of the rapid response team in priority order. All options must be used. 1. Place client in high flowers position 2. Perform oropharyngeal suctioning 3. Administer 100% oxygen by non rebreather mask 4. Assess lung sounds 5, Notify primary healthcare provider

1. Place client in high flowers position 2. Perform oropharyngeal suctioning 3. Administer 100% oxygen by non rebreather mask 4. Assess lung sounds 5, Notify primary healthcare provider (in correct order)

A nurse is reviewing the laboratory results of a client admitted for an asthma exacerbation. Elevation of which of these cells indicates that the client's asthma may have been triggered by an allergic response? 1. Eosinophils 2. Lymphocytes 3. Neutrophils 4. Reticulocytes

1. Eosinophils

The nurse is providing care for a client with cancer of the left lung who will undergo video-assisted thoracic surgery in the morning. The client is nervous, jumpy, and short of breath. Pulse is 120/min, respirations are 30/min and shallow,and expiratory wheezing is auscultated in the left upper and lower lung posteriorly. Which of the following is the priority nursing action? 1. Administer prescribed intravenous morphine 2 mg to relieve anxiety 2. Page respiratory therapist to administer inhaled bronchodilator nebulizer treatment 3. Place head of the bed in Fowler's or high Fowler's position 4. Stay with client and encourage client to discuss feelings about the surgery

3. Place head of the bed in Fowler's or high Fowler's position

The nurse receives the handoff of care report on four clients. Which client should the nurse see first? 1. Client reporting incisional pain of 8 on a scale of 0-10 with a respiratory rate of 25/min who had a right pneumonectomy 12 hours ago 2. Client with a left pleural effusion who has crackles, absent breath sounds in the left base, and an SpO2 of 94% on room air 3. Client with a temperature of 100.4 F (38 C) and a respiratory rate of 12/min who had a small bowel resection 1 day ago 4. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO, of 93% on 4 L/min supplemental oxygen, and is becoming restless

4. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO, of 93% on 4 L/min supplemental oxygen, and is becoming restless

The nurse is caring for a 72-year-old client 1 day postoperative colectomy. The nurse assesses an increased work of breathing, diminished breath sounds at the bases with fine inspiratory crackles, respirations 12/min and shallow, and pulse oximetry 96% on 2 L oxygen. There is no jugular venous distension or peripheral edema. Pain is regulated with client-controlled morphine. Which prescription does the nurse anticipate? 1. Bolus dose of IV morphine 2. Incentive spirometer 3. IV furosemide 4. Non-rebreather mask

2. Incentive spirometer

**Exhibit** PH : 7.25 PO2: 79 mm Hg (10.5 kPa) PaCO2 35 mm Hg (4.66 kPa) HCO3: 12 mEq/L (12 mmol/L) A client's arterial blood gasses (ABGs) are shown in the exhibit. The nurse would expect which finding to demonstrate that the client is compensating for the ABGs? Click on the exhibit button for additional information. 1. Decrease in bicarbonate reabsorption 2. Decrease in respiratory rate 3. Increase in bicarbonate reabsorption 4. Increase in respiratory rate

4. Increase in respiratory rate

The nurse caring for a client with left lobar pneumonia responds to an alarm from the continuous pulse oximeter. The client is short of breath with an oxygen saturation of 78%. After applying oxygen, the nurse should place the client in which position to improve oxygenation? 1. Left lateral 2. Right lateral 3. Supine 4. Trendelenburg

2. Right lateral

## Footnote A home health nurse visits a client with chronic obstructive pulmonary disease. The nurse teaches the client to use abdominal breathing to perform the "huff" cough technique to facilitate secretion removal. Place the steps in the correct order. All options must be used. 1. “Sit upright in a chair with feet spread shoulder-width apart and lean forward” 2. “Perform a slow, deep inhalation with your mouth using your diaphragm” 3. “Hold your breath for 2-3 seconds and then forcefully exhale quickly.” 4. “Repeat the huff once or twice more, while refraining from performing a normal cough.” 5. “Rest for 5-10 normal breaths and repeat as necessary until mucus is cleared.”

1. “Sit upright in a chair with feet spread shoulder-width apart and lean forward” 2. “Perform a slow, deep inhalation with your mouth using your diaphragm” 3. “Hold your breath for 2-3 seconds and then forcefully exhale quickly.” 4. “Repeat the huff once or twice more, while refraining from performing a normal cough.” 5. “Rest for 5-10 normal breaths and repeat as necessary until mucus is cleared.”

The client with malignant left pleural effusion undergoes a thoracentesis and 900 mL of excess pleural fluid is removed. Which of these manifestations, if noted on the post-procedure assessment, should the nurse report to the health care provider immediately? 1. Asymmetrical chest expansion and decreased breath sounds on the left 2. Blood pressure 100/65 mm Hg (mean arterial pressure 77 mm Hg) 3. Client complains of 6/10 pain at the needle insertion site 4. Respiratory rate 24/min, pulse oximetry 94% on oxygen 2 L/min

1. Asymmetrical chest expansion and decreased breath sounds on the left

Exhibit #56 A client with pneumonia is transferred from the medical unit to the intensive care unit due to sepsis and worsening respiratory failure. Based on the nurse's progress note, which assessment data are most important for the nurse to report to the health care provider (HCP)? Click on the exhibit button for additional information. 1. Cough with mucus production 2. Refractory hypoxemia 3. Scattered rhonchi and crackles 4. Temperature 101 F (38.3 C)

2. Refractory hypoxemia

The nurse provides instruction to a community group about lung cancer prevention, health promotion, and smoking cessation. Which statement made by a member of the group indicates the need for further instruction? 1"Even though I am getting nicotine in my patches, I am not being exposed to all of the other toxic stuff in cigarettes." 2. "I can't get lung cancer because I don't smoke." 3. "My husband needs to take smoking cessation classes." 4. "We installed a radon detector in our home."

2. "I can't get lung cancer because I don't smoke."

The office nurse instructs a client newly diagnosed with asthma about the use of the peak flow meter to evaluate airflow. Which statement made by the client indicates an understanding of the nurse's teaching? 1. "I will exhale as quickly and forcibly as possible through the mouthpiece of the device to obtain a peak flow reading." 2. "I will move the indicator to the desired reading on the numbered scale before using the device." 3. "I will record my personal best reading, which is the average of 3 consecutive peak flow readings." 4. "I will remember to use the device after taking my fluticasone metered-dose inhaler (MDI)."

1. "I will exhale as quickly and forcibly as possible through the mouthpiece of the device to obtain a peak flow reading.

The nurse is assessing a 3-year-old client in the emergency department and finds dyspnea, high fever, irritability, and open-mouthed drooling with leaning forward. The parents report that the symptoms started rather abruptly. The client has not received age-appropriate vaccinations. Which set of actions should the nurse anticipate? 1. 20-gauge needle insertion at the mid-axillary line for pleural aspiration 2. 4 L oxygen at 100% per nasal cannula with bilevel positive airway pressure (BPAP) ventilation standing by 3. Intubation in the operating room with a prepared tracheotomy kit standing by 4. Nebulized racemic epinephrine with pediatric anesthesiologist standing by

3. Intubation in the operating room with a prepared tracheotomy kit standing by

An obese 85-year-old client, who is an avid gardener and eats only home-grown fruits, legumes, and vegetables, is admitted to the hospital with pneumonia after having an upper respiratory tract infection for a week. Which factor puts the client at greatest risk for developing pneumonia? 1. Advanced age 2. Environmental exposure 3. Nutritional deficit 4. Obesity

1. Advanced age

A client is transferred from the post-anesthesia recovery unit to the surgical unit following an open cholecystectomy. Which interventions are most important for the nurse to perform to prevent postoperative pneumonia? Select all that apply. 1. Administer morphine only if the pain is \>8 on a 1-10 pain scale 2. Ambulate within 8 hours after surgery, if possible 3. Have client cough with splinting every hour 4. Have client deep breathe and use the incentive spirometer every hour 5. Maintain pneumatic compression devices when client is in bed 6. Place client in Fowler's position

2. Ambulate within 8 hours after surgery, if possible 3. Have client cough with splinting every hour 4. Have client deep breathe and use the incentive spirometer every hour 6. Place client in Fowler's position

A client with chronic kidney disease has a large pleural effusion. What findings characteristic of a pleural effusion does the nurse expect? Select all that apply. 1. Chest pain during inhalation 2. Diminished breath sounds 3. Dyspnea 4. Hyperresonance on percussion 5. Wheezing

1. Chest pain during inhalation 2. Diminished breath sounds 3. Dyspnea

The school nurse assesses an 8-year-old with a history of asthma. The nurse notes mild wheezing and coughing Which action should the nurse perform first? 1. Assess the client's peak expiratory flow 2. Call the health care provider (HCP) 3. Educate the client about avoiding triggers 4. Notify the client's parents

1. Assess the client's peak expiratory flow

The nurse assesses a child who has been treated for an acute asthma exacerbation. Which client assessment is the best indicator that treatment has been effective? 1. Episodes of spasmodic coughing have decreased 2. No wheezes are audible on chest auscultation 3. Oxygen saturation has increased from 88% to 93% 4. Peak expiratory flow rate has dropped from 212 L/min to 127 L/min

3. Oxygen saturation has increased from 88% to 93%

The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate? Select all that apply. 1. Bradycardia 2. Chest pain 3. Dyspnea 4. Hypoxemia 5. Tachypnea 6. Tracheal deviation

2. Chest pain 3. Dyspnea 4. Hypoxemia 5. Tachypnea

The nurse assesses a client with a history of cystic fibrosis who is being admitted due to a pulmonary exacerbation.Which assessment finding requires immediate action by the nurse? 1. Decrease in SpO, from baseline 92% to 88% on room air 2. Expectorating blood-tinged sputum 3. Loss of appetite and recent 5 lb (2.3 kg) weight loss 4. No bowel movement for 2 days and right lower quadrant discomfort

1. Decrease in SpO, from baseline 92% to 88% on room air

Client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse? 1. "After taking this medication, I will rinse my mouth with water." 2. "At the first sign of an asthma attack, I will take this medication." 3. "I have been smoking for 12 years, but I just quit a month ago." 4. "I received the pneumococcal vaccine about a month ago."

2. "At the first sign of an asthma attack, I will take this medication."

An elderly client is prescribed codeine for a severe cough. The home health nurse teaches the client how to prevent the common adverse effects associated with codeine. Which client statements indicate an understanding of how to prevent them? Select all that apply. 1. "I'II be sure to apply sunscreen if I go outside." 2. "I'Il drink at least 8 glasses of water a day." 3. "I'II drink decaffeinated coffee so I can sleep at night." 4. "I'Il sit on the side of my bed for a few minutes before getting up." 5. "I'll take my medicine with food”

2. "I'Il drink at least 8 glasses of water a day." 4. "I'Il sit on the side of my bed for a few minutes before getting up." 5. "I'll take my medicine with food”

Exhibit: coarse crackles (loud, low pitched bubbling) The nurse auscultates the lung sounds of a client with shortness of breath. Based on the sounds heard, which action would the nurse anticipate? Listen to the audio clip. (Headphones are required for best audio quality.) 1. Administer albuterol via nebulizer 2. Administer furosemide IV push 3. Instruct to use pursed-lip breathing 4. Prepare for chest tube insertion

2. Administer furosemide IV push

A nurse in a clinic is caring for an 8-month-old with a new diagnosis of bronchiolitis due to respiratory syncytial virus (RSV). Which instructions can the nurse anticipate reviewing with the parent? 1. Administering a cough suppressant and antihistamine 2. Prophylactic treatment of family members 3. Temporary cessation of breastfeeding 4. Use of saline drops and a bulb syringe to suction nares

4. Use of saline drops and a bulb syringe to suction nares

A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress. While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration. What immediate action does the RN take to correct the problem? 1. Elevates the head of the bed 2. Increases the oxygen flow 3. Opens both flutter valves (ports) on the mask 4. Tightens the face mask straps

2. Increases the oxygen flow

A client is brought to the emergency department following a motor vehicle collision. The client's admission vital signs are blood pressure 70/50 mm Hg, pulse 123/min, and respirations 8/min. The nurse anticipates the results of which diagnostic test to best evaluate the client's oxygenation and ventilation status? 1. Arterial blood gases 2. Chest x-ray 3. Hematocrit and hemoglobin levels 4. Serum lactate level

1. Arterial blood gases

A nurse is caring for a college athlete who was recently diagnosed with moderate persistent asthma. Which common asthma trigger should the nurse teach this client to avoid? 1. Latex-containing products 2. Penicillin antibiotics 3. Secondhand cigarette smoke 4. Strenuous physical activity

3. Secondhand cigarette smoke

A client is admitted with a pulmonary embolus. The nurse assesses restlessness, one-word dyspnea and shortness of breath with activity, tachycardia, pleuritic chest pain, and severe anxiety. Arterial blood gases indicate respiratory alkalosis and hypoxemia. When initiating the care plan, the nurse should choose which nursing diagnosis as the highest priority? 1. Activity intolerance related to imbalance between oxygen supply and demand 2. Acute pain related to inspiration and inflammation of pleura 3. Anxiety related to fear of the unknown, chest pain, and dyspnea 4. Impaired gas exchange related to ventilation-perfusion imbalance

4. Impaired gas exchange related to ventilation-perfusion imbalance

A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which interventions can the nurse suggest to help mobilize secretions and improve sleep? Select all that apply. 1. Increase fluids to at least 8 glasses (2-3 L) of water a day 2. Sleep with a cool mist humidifier 3. Take prescribed guaifenesin cough medicine before bedtime 4. Use abdominal breathing and the huff cough technique at bedtime 5. Use pursed-lip breathing during the night

1. Increase fluids to at least 8 glasses (2-3 L) of water a day 2. Sleep with a cool mist humidifier 3. Take prescribed guaifenesin cough medicine before bedtime 4. Use abdominal breathing and the huff cough technique at bedtime

A nursing diagnosis of “ineffective airway clearance related to pain” is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first? 1. Administer prescribed analgesic medication for incisional pain 2. Encourage use of incentive spirometer every 2 hours while awake 3. Offer an additional pillow to splint the incision while coughing 4. Promote increased oral fluid intake

1. Administer prescribed analgesic medication for incisional pain

The client has a chest tube for a pneumothorax. While repositioning the client for an xray, the technician steps on the tubing and accidentally pulls the chest tube out. The client’s oxygen saturation drops and the pulse is 132/min; the nurse hears air leaking from the insertion site. Which is the nurse’s immediate action? 1. Apply an occlusive sterile dressing secured on 3 sides 2. Apply an occlusive sterile dressing secured on 4 sides 3. Assess lung sounds 4. Notify the health care provider (HCP)

1. Apply an occlusive sterile dressing secured on 3 sides

The nurse in the outpatient procedure unit is caring for a client immediately post bronchoscopy. Which assessment data indicate that the nurse needs to contact the health care provider immediately? 1. Absence of gag reflex 2. Bright red blood mixed with sputum 3. Headache 4. Respirations 10/min and saturation of 92%

2. Bright red blood mixed with sputum

A nurse in an urgent care center triages multiple clients. Which client should the nurse assess first? 1. Client who reports nosebleed that has not resolved after holding pressure for 1 hour 2. Client who reports sinus congestion with thick nasal drainage and severe facial pain 3. Client with a sore throat who reports difficulty in opening mouth and swallowing 4. Client with seasonal allergies who reports new onset of unilateral ear pain and pressure

3. Client with a sore throat who reports difficulty in opening mouth and swallowing

An obese 85 year old client who is an avid gardener and eats only home grown fruits, legumes, and vegetables is admitted to the hospital with pneumonia after having an upper respiratory tract infection for a week. Which factor puts the client at greatest risk for developing pneumonia? 1. Advanced age 2. Environmental exposure 3. Nutritional deficit 4. Obesity

1. Advanced age

A hospitalized client with a history of obstructive sleep apnea sleeps while wearing a full face mask with continuous positive airway pressure (CPAP). Oxygen saturation drops to 85% during the night. What is the nurse’s first action? 1. Assess level of consciousness and lung sounds. 2. Check the tightness of the straps and mask 3. Notify the health care provider immediately 4. Remove the mask and administer supplemental oxygen

2. Check the tightness of the straps and mask

A self-employed auto mechanic is diagnosed with carbon monoxide poisoning. Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air. What is the nurse’s priority action? 1. Administer 5 mg inhaled albuterol nebulizer treatment to decrease inflammatory bronchoconstriction 2. Administer 100% oxygen using a nonrebreather mask with flow rate of 15L/min 3. Administer methylprednisolone to decrease lung inflammation from toxic inhalant 4. Titrate oxygen to maintain pulse oximeter saturation of \>95%

2. Administer 100% oxygen using a nonrebreather mask with flow rate of 15L/min

The nurse is caring for a client with a chest tube that was placed 2 hours ago for a pneumothorax. Where would the nurse expect gentle, continuous bubbling? 1. Air leak monitor 2. Collection chamber 3. Suction control chamber 4. Water seal chamber

3. Suction control chamber

A 64 year old hospitalized client with chronic obstructive pulmonary disease exaceration has increased lethargy and confusion. The client’s pulse oximetry is 88% oon 2 liters of oxygen. Arterial blood gas analysis shows a pH of 7.25, PO2 of 60 mmHg (8.o kPa), and PCO2 of 80 mmHg (10.6 kPa). Which of the following should the nurse implement first? 1. Administer PRN nebulizer treatment 2. Administer scheduled dose of methylprednisolone IV 3. Increased client’s oxygen to 4 liters 4. Place client on the bilevel positive airway pressure (BIPAP) machine

4. Place client on the bilevel positive airway pressure (BIPAP) machine

The nurse takes the admission history of a 70 year old client diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following statements by the client does the nurse recognize as contributing to the development of COPD? Select all that apply. 1. “I have been drinking alcohol almost daily since age 20” 2. “I have been overweight for as long as I can remember” 3. “I have smoked about a pack of cigarettes a day since i was 16 years old but quit last year” 4. “I know I eat too much fast food” 5. “I was a car mechanic for about 40 years and had my own garage”

3. “I have smoked about a pack of cigarettes a day since i was 16 years old but quit last year” 5. “I was a car mechanic for about 40 years and had my own garage”

A client admitted with exacerbation of asthma following a respiratory viral illness. Which clinical manifestations characteristic of a severe asthma attack does the nurse expect to assess? Select all that apply. 1. Accessory muscle use 2. Chest tightness 3. High pitched expiratory wheeze 4. Prolonged inspiratory phase 5. Tachypnea

1. Accessory muscle use 2. Chest tightness 3. High pitched expiratory wheeze 5. Tachypnea

A client comes to the emergency department and reports headache, nausea, and shortness of breath after being stranded at home without electricity due to severe winter weather. While collecting a history, which question is most important for the nurse to ask? 1. “Are you up to date with your annual flu shot and other vaccinations?” 2. “Have you had difficulty eating or drinking in the last few days?” 3. “How have you been keeping your house warm during this weather?” 4. “Is there anything that you have found that relieves your symptoms?”

3. “How have you been keeping your house warm during this weather?”

An elderly client is admitted with chronic obstructive pulmonary disease (COPD) exacerbation. Pulse oximetry is 84% on room air. The client is restless, has expiratory wheezing and a productive cough, and is using his accessory muscles to breathe. Which prescription should the nurse question? 1. Albuterol 2.5 mg by nebulizer 2. Intravenous (IV) methylprednisolone 125 mg now and every 6 hours 3. IV morphine 2 mg now and may repeat every 2 hours 4. Oxygen at 2 L/min by nasal cannula

3. IV morphine 2 mg now and may repeat every 2 hours

The nurse is caring for a client admitted with incomplete fractures of right ribs 5-7. The nurse notes shallow respirations, and the client reports deep pain on inspiration. What is the priority at this time? 1. Administer prescribed IV morphine 2. Facilitate hourly client use of incentive spirometry 3. Instruct client on gently splinting injury during coughing 4. Notify the health care provider immediately

1. Administer prescribed IV morphine

A client is scheduled for allergy skin testing to identify asthmatic triggers. Which medications should the nurse instruct the client to withhold before the test to ensure accurate results? Select all that apply. 1. Acetaminophen 2. Albuterol 3. Diphenhydramine 4. Enalapril 5. Loratadine

3. Diphenhydramine 5. Loratadine

The home care nurse is making an initial visit to a client just discharged after admission for severe exacerbation of chronic obstructive pulmonary disease (COPD). The nurse observes wall to wall stacks of old newspapers and magazines in every room with pathways that just allow passages from one room to another. What is the priority nursing action? 1. Call the mobile community mental health crisis unit 2. Contact a service to remove the newspapers and magazines 3. Reconcile the client’s discharge medications 4. Teach the safe use of oxygen

4. Teach the safe use of oxygen

The nurse in the postanesthesia care unit (PACU) is caring for an unresponsive client who just came from the operating room following surgery under general anesthetic for colorectal cancer. The nurse chooses what as the highest priority nursing diagnosis (ND)? 1. Acute pain 2. Impaired physical mobility 3. Ineffective airway clearance 4. Risk for fluid volume deficit

3. Ineffective airway clearance

The home health nurses visits a 72 year old client with pneumonia who was discharged from the hospital 3 days ago. The client has less of a productive cough at night but now reports sharp chest pain with inspiration. Which finding is most important for the nurse to report to the health care provider? 1. Bronchial breath sounds 2. Increased tactile fremitus 3. Low pitched wheezing (rhonchi) 4. Pleural friction rub

4. Pleural friction rub

The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse’s priority when caring for a client with a new tracheostomy? 1. Changing the inner cannula within the first 8 hours to help prevent mucus plugs 2. Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties 3. Deflating and re-inflating the cuff every 4 hours to prevent mucosal tissue damage 4. Performing frequent mouth care every 2 hours to help prevent infection

2. Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties

A client has chronic obstructive pulmonary disease (COPD) exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse assesses diminished lung sounds and low pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use accessory muscles. What is the most appropriate oxygen delivery device for this client? 1. Nasal cannula 2. Non-rebreathing mask 3. Oxymizer 4. Venturi mask

4. Venturi mask

The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention? 1. Assess pupillary response 2. Auscultate lung sounds 3. Inform anesthesia professional 4. Perform head tilt and chin tilt

4. Perform head tilt and chin tilt

A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless. He has been given intravenous morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas (ABG) results best indicate that the client is in acute respiratory failure (ARF) and needs immediate intervention? 1. PaO2 49 mm Hg (6.5 kPa), PaCO2 60 mm Hg (8.0 kPa) 2. PaO2 64 mm Hg (8.5 kPa), PaCO2 45 mm Hg (6.0 kPa) 3. PaO2 70 mm Hg (9.3 kPa), PaCO2 30 mm Hg (4.0 kPa) 4. PaO2 86 mm Hg (11.5 kPa), PaCO2 25 mm Hg (3.33 kPa)

1. PaO2 49 mm Hg (6.5 kPa), PaCO2 60 mm Hg (8.0 kPa)

Several children are brought to the emergency room after a boating accident in which they were thrown into the water. The children are now 6 hours post admission to the clinical observation unit. Which client should the nurse evaluate first? 1. Client who did not require CPR but now has a new oxygen requirement of 2 L via nasal cannula to maintain a saturation of 95% 2. Client who did not require CPR but was coughing on arrival to the hospital and is now crying inconsolably and asking for the mother 3. Client who received CPR for 2 minutes on the scene and whose respiratory rate has now dropped from 61/min to 18/min 4. Client who was briefly submerged in water and received rescue breaths on the scene and is now irritable and refusing food and drink

3. Client who received CPR for 2 minutes on the scene and whose respiratory rate has now dropped from 61/min to 18/min

\*\*The nurse is assisting a client with asthma perform a peak flow meter measurement. Place the instructions for measuring peak expiratory flow using a peak flow meter in the correct order. All options must be used. 3. Position the indicator on the flow meter scale to the lowest value and assume an upright position 2. Inhale deeply, place mouthpiece in mouth, and use the lips to create the seal 1. Exhale as quickly and completely as possible and note the reading on the scale 5. Repeat the procedure 2 more times with a 5-10 second rest period between exhalations 4. Record the highest of the three measured values in the peak flow log

3. Position the indicator on the flow meter scale to the lowest value and assume an upright position 2. Inhale deeply, place mouthpiece in mouth, and use the lips to create the seal 1. Exhale as quickly and completely as possible and note the reading on the scale 5. Repeat the procedure 2 more times with a 5-10 second rest period between exhalations 4. Record the highest of the three measured values in the peak flow log

The triage nurse is assessing an unvaccinated 4-month-old infant for fever, irritability, and open-mouthed drooling. After the infant is successfully treated for epiglottis, the parents wonder how this could have been avoided. Which response by the nurse would be most appropriate? 1. “It’s impossible to know for sure what could have caused this episode.” 2. “Most cases of epiglottis are preventable by standard immunizations.” 3. “We are still waiting for the formal report from the microbiology laboratory.” 4. “There is nothing you could have done, the important thing is that your child is safe now.”

2. “Most cases of epiglottis are preventable by standard immunizations.”

Based on the lung assessment information included in the hand-off report, which client should the nurse assess first? 1. Client 1-day postoperative abdominal surgery who has fine inspiratory crackles at the lung bases 2. Client with chronic bronchitis who has rhonchi in the anterior and posterior chest 3. Client with right-sided pleural effusion who has decreased breath sounds at the right lung base 4. Client with severe acute pancreatitis who has inspiratory crackles at the lung bases

4. Client with severe acute pancreatitis who has inspiratory crackles at the lung bases

The nurse is providing discharge instructions on the proper use of prescribed short-acting beta agonist and inhaled corticosteroid metered-dose inhalers to a client with newly diagnosed asthma. Which instructions should the nurse include? Select all that apply. 1. “Omit the beclomethasone if the albuterol is effective.” 2. “Rinse your mouth well after using the beclomethasone inhaler and do not swallow the water.” 3. “Take the albuterol inhaler apart and wash it after every use.” 4. “Use the albuterol inhaler first if needed, then the beclomethasone inhaler.” 5. “Use the beclomethasone inhaler first, then the albuterol, if needed.”

2. “Rinse your mouth well after using the beclomethasone inhaler and do not swallow the water.” 4. “Use the albuterol inhaler first if needed, then the beclomethasone inhaler.”

After receiving a change-of-shift report, the nurse should assess which client first? 1. Client recently admitted with a positive tuberculin skin test who reports hemoptysis 2. Client who had abdominal surgery yesterday and refuses incentive spirometry 3. Client who has just returned to the floor after undergoing a bronchoscopy 4. Client with a chest tube drainage system with air bubbles in the suction control chamber

3. Client who has just returned to the floor after undergoing a bronchoscopy

The charge nurse of the emergency department (ED) is mentoring a new registered nurse (RN). They are caring for a client who has a chest tube connected to wall suction for a pneumothorax. The client is being transferred from the ED to the telemetry unit. Which action by the new RN would cause the charge nurse to intervene? 1. Clamping the chest tube at the insertion site during the transfer 2. Discontinuing thes auction tubing from the wall suction unit 3. Hanging the chest tube collection unit to the underside of the stretcher 4. Taping connections between the chest tube and suction tubing

1. Clamping the chest tube at the insertion site during the transfer

A client with bronchial asthma and sinusitis has increased wheezing and decreased peak flow readings. During the admission interview, the nurse reconciles the medications and notes that which of the following over-the-counter medications taken by the client could be contributing to increased asthma symptoms? 1. Guaifenesin 600 mg orally twice a day as needed 2. Ibuprofen 400 mg orally every 6 hours for pain as needed a. Can cause bronchospasm in some clients with asthma 3. Loratadine 1 tablet orally every day as needed 4. Vitamin D 2,000 units orally every day

2. Ibuprofen 400 mg orally every 6 hours for pain as needed

The nurse auscultates the lung sounds of a newly admitted client. The nurse understands that the lung sounds heard are consistent with which health condition? Listen to the audio clip. **Exhibit:** Rhonchi are continuous, low-pitched adventitious breath sounds similar to moaning or snoring that occur when thick secretions or foregin bodies (eg, tumors) obstruct airflow in the upper airways 1. Bronchitis 2. Croup 3. Pleurisy 4. Pneumothorax

1. Bronchitis

A client was medicated with intravenous morphine 2 mg 2 hours ago to relieve moderate abdominal pain after appendectomy. The client becomes lethargic but arouses easily to verbal and tactile stimuli, and is oriented to time, place and person. The pulse oximeter reading has dropped from 99% to 89% on room air. Which oxygen delivery device is the most appropriate for the nurse to apply?

The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak? 1. Section A 2. Section B 3. Section C 4. Section D

3. Section C

The nurse is teaching a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required? 1. “I need to avoid caffeinated products.” 2. “I need to get my blood drug levels checked periodically” 3. “I need to report anorexia and sleeplessness.” 4. “I take cimetidine rather than omeprazole for heartburn.” - Cimetidine increases serum theophylline levels

4. “I take cimetidine rather than omeprazole for heartburn.”

The nurse is teaching a 9-year old child with asthma how to use a metered-dose inhaler (MDI). Place the instructions in the appropriate order. All options must be used. 1. Exhale completely 2. Deliver one puff of medication into spacer 3. Place lips tightly around the mouth piece 4. Rinse mouth with water 5. Shake MDI and attach it to spacer 6. Take a slow deep breath and hold for 10 seconds

5. Shake MDI and attach it to spacer 1. Exhale completely 3. Place lips tightly around the mouth piece 2. Deliver one puff of medication into spacer 6. Take a slow deep breath and hold for 10 seconds 4. Rinse mouth with water

A pediatric client is diagnosed with an acute asthma attack. Which immediate-acting medications should the nurse prepare to administer to this client? Select all that apply. 1. Albuterol 2. Ibuprofen 3. Ipratropium 4. Montelukast 5. Tobramycin

1. Albuterol 3. Ipratropium

A nurse is caring for a child who is receiving oxygen at 2 L/min by nasal cannula and observes the current oxygen saturation and pulse plethysmographic waveform on the pulse oximeter. Which intervention should be the nurse’s initial action? Click the exhibit button for additional information. Exhibit: O2 sat is at 83% 1. Auscultate the child’s lung fields 2. Have the child take slow, deep breaths 3. Increase the oxygen flow rate to 3 L/min 4. Verify the position and integrity of the finger probe

4. Verify the position and integrity of the finger probe

1. Digoxin level 2. Glucose 4. Platelet count 5. Serum potassium

2. Potassium level of 4.2 mEq/L

The nurse is admitting a client with heart failure-related fluid overload. Which action should the nurse complete first? 1. Administer oxygen 2. Assess the client’s breath sounds 3. Initiate cardiac monitoring 4. Insert a peripheral IV catheter

2. Assess the client’s breath sounds

A client is 48 hours post abdominal aneurysm repair. Which assessment by the nurse is cause for greatest concern? 1. Diminished breath sounds in bilateral lung bases 2. Hypoactive bowel sounds in all 4 quadrants 3. Urinary output of 90 mL in the past 4 hours 4. Warm extremities with 1+ bilateral pedal pulses

3. Urinary output of 90 mL in the past 4 hours

The nurse evaluating a 52-year-old diabetic male client’s therapeutic response to rosuvastatin would notice changes in which laboratory values? SATA 1. Alanine aminotransferase from 20 U/L to 80 U/L 2. High-density lipoprotein cholesterol from 48 mg/dL to 30 mg/dL 3. Low-density lipoprotein cholesterol from 176 mg/dL to 98 mg/dL 4. Total cholesterol from 250 mg/dL to 180 mg/dL 5. Triglycerides from 180 mg/dL to 149 mg/dL

3. Low-density lipoprotein cholesterol from 176 mg/dL to 98 mg/dL 4. Total cholesterol from 250 mg/dL to 180 mg/dL 5. Triglycerides from 180 mg/dL to 149 mg/dL

A client is admitted with palpitations. The ECG shows supraventricular tachycardia (SVT) with a rate of 220/min. The nurse has received an order to administer adenosine 6 mg IV. which action should the nurse take? 1. Adenosine is contraindicated for SVT. Verify the order with the health care provider 2. Administer medication only through a central venous access 3. Administer medication rapidly over 1-2 seconds followed by a saline flush 4. Mix medication in 50 mL normal saline and administer over 10 minutes

3. Administer medication rapidly over 1-2 seconds followed by a saline flush

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? SATA 1. I will apply moisturizing lotion on my legs every day 2. I will elevate my legs at night when I am sleeping 3. I will keep my legs below my heart level when sitting 4. I will start walking outside with my neighbor 5. I will use a heating pad to promote circulation

1. I will apply moisturizing lotion on my legs every day 3. I will keep my legs below my heart level when sitting 4. I will start walking outside with my neighbor

A 62-year-old client is scheduled for open abdominal aneurysm repair. What key assessment should be made by the nurse preoperatively? 1. Assess and compare blood pressure in each arm 2. Assess character and quality of peripheral pulses 3. Assess for presence or absence of hair on lower extremities 4. Assess for presence of bowel sounds

2. Assess character and quality of peripheral pulses

2. Assess the client’s breath sounds

3. Urinary output of 90 mL in the past 4 hours

3. Low-density lipoprotein cholesterol from 176 mg/dL to 98 mg/dL 4. Total cholesterol from 250 mg/dL to 180 mg/dL 5. Triglycerides from 180 mg/dL to 149 mg/dL

1. Adenosine is contraindicated for SVT. Verify the order with the health care provider

1. I will apply moisturizing lotion on my legs every day 3. I will keep my legs below my heart level when sitting 4. I will start walking outside with my neighbor

2. Assess character and quality of peripheral pulses

The unlicensed assistive personnel reports a client blood pressure of 90/60 mm Hg to the nurse. The client’s prescriptions say to notify the health care provider (HCP) if systolic blood pressure is \<100 mm Hg. What should the nurse do first? 1. Assess the client for other signs and symptoms 2. Immediately notify the client’s HCP 3. Notify the charge nurse on duty for the shift 4. Review the client’s medication administration record

1. Assess the client for other signs and symptoms

The nurse is assessing a client 15 minutes after initiating nitroglycerin infusion for suspected acute coronary syndrome. Which clinical finding is the priority? 1. The client reports a headache 2. The client reports feeling dizzy and lightheaded 3. The client reports feeling flushed 4. The client reports feeling nervous

2. The client reports feeling dizzy and lightheaded

A nurse is teaching the parents of an infant with tetralogy of Fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells? SATA 1. Encourage smaller, frequent feedings 2. Offer a pacifier when the infant begins to cry 3. Promote a quiet period upon waking in the morning 4. Swaddle the infant during procedures 5. Turn the infant frequently during sleep

1. Encourage smaller, frequent feedings 2. Offer a pacifier when the infant begins to cry 3. Promote a quiet period upon waking in the morning 4. Swaddle the infant during procedures

The nurse is caring for a child with Kawasaki disease who is receiving IV immunoglobulin. The child’s parent wants to know why this treatment is required. The nurse explains that this therapy is given to: 1. Fight the infection 2. Minimize rash 3. Prevent heart disease 4. Reduce spleen size

3. Prevent heart disease

A clinic nurse is caring for a client who has hypertension and is prescribed hydrochlorothiazide, lisinopril, and clonidine. The current blood pressure reading is 190/102 mm Hg, and the client reports a headache that has lasted several days. Which question is most important for the nurse to ask next? 1. Have you noticed any abnormal swelling in your legs? 2. How are you currently taking your blood pressure medications? 3. How has your stress level been the past few weeks? 4. What over-the-counter medications have you taken today?

2. How are you currently taking your blood pressure medications?

A client with unstable angina and chronic kidney disease is receiving a continuous infusion of unfractionated heparin. Which value for activated partial thromboplastin time (aPTT) would indicate to the nurse that the heparin therapy is at an optimal therapeutic level? 1. 30 seconds 2. 35 seconds 3. 60 seconds 4. 85 seconds

3. 60 seconds

The nurse is preparing to administer 160 mg of furosemide via IV piggyback to a client with chronic kidney disease and fluid overload. The nurse plans to give the dose slowly over 40 minutes to prevent which adverse effect? 1. Bradycardia 2. Hypokalemia 3. Nephrotoxicity 4. Ototoxicity

4. Ototoxicity

A nurse in the emergency department is titrating a continuous infusion of nitroglycerin to a client admitted for acute coronary syndrome. The client’s vital signs, including blood pressure (BP), heart rate (HR), and pain level, are being monitored frequently. Which assessment findings indicate that the current rate of administration should be maintained? 1. BP 80/50 mm Hg, HR 110/min; client reports pain is 0 out of 10 2. BP 100/60 mm Hg, HR 90/min; client reports pain is 3 out of 10 3. BP 110/70 mm Hg, HR 80/min; client reports pain is 0 out of 10 4. BP 120/80 mm Hg, HR 70/min; client reports pain is 5 out of 10

3. BP 110/70 mm Hg, HR 80/min; client reports pain is 0 out of 10

Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency? 1. Brownish, hardened skin on lower extremities 2. Diminished peripheral pulses 3. Non Healing ulcer on lateral surface of great toe 4. Shiny, hairless lower extremities

1. Brownish, hardened skin on lower extremities

A client is receiving a continuous heparin infusion and the most recent aPTT is 140 seconds. The nurse notices blood oozing at the surgical incision and IV insertion sites. What interventions should the nurse implement? SATA 1. Continue heparin infusion and recheck aPTT in 6 hours 2. Prepare to administer vitamin K 3. Redraw blood for laboratory tests 4. Review guidelines for administration of protamine 5. Stop infusion of heparin and notify the health care provider (HCP)

4. Review guidelines for administration of protamine 5. Stop infusion of heparin and notify the health care provider (HCP)

The nurse in the outpatient clinic is reviewing phone messages. Which client should the nurse call back first? 1. Client post kidney transplant who reports white spots in the oral cavity 2. Client with a history of mitral valve regurgitation who reports fatigue 3. Client with erythema and purulent drainage at the site of a spider bite 4. Client with hypertension who reports a cold and nasal congestion

2. Client with a history of mitral valve regurgitation who reports fatigue

The nurse is teaching a client who is scheduled to have an INFERIOR VENA CAVA FILTER inserted via the right femoral vein. Which statement by the client requires FURTHER teaching? 1. "I need to make all health care providers aware of my filter before I have body scans" 2. "I need to stay active and avoid crossing my legs for extended periods when I get home" 3. "I should call the health care provider if I develop numbness, tingling and swelling in my right leg." 4. "It is normal to have some chest or back discomfort for a few days after filter placement. "

4. "It is normal to have some chest or back discomfort for a few days after filter placement. "

The nurse is reviewing a client’s health history during a primary care visit. Which of the following findings should the nurse identify as risk factors for developing hypertension? SATA 1. African American ethnicity 2. Diabetes mellitus type 2 3. Frequent stress at work 4. LDL of 94 mg/dL 5. Smoking of 1 pack of cigarettes daily

1. African American ethnicity 2. Diabetes mellitus type 2 3. Frequent stress at work 5. Smoking of 1 pack of cigarettes daily

The nurse is performing an initial assessment on a client in hypertensive crisis. What is the nurse’s priority assessment? Blood pressure 210/120 mm Hg Heart rate 109/min Respirations 20/min O2 saturation 96% 1. Heart sounds 2. Level of consciousness 3. Lung sounds 4. Visual fields and acuity

2. Level of consciousness

A home health nurse is preparing to start a milrinone infusion via a peripherally inserted central catheter for a client with end-stage heart failure. What equipment is most important to be present in the home? Select all that apply. 1. Bathroom scale for daily weights 2. Blood pressure cuff 3. Central line dressing change kits 4. Infusion pump 5. Intermittent urinary catheterization kits

1. Bathroom scale for daily weights 2. Blood pressure cuff 3. Central line dressing change kits 4. Infusion pump

The nurse reinforces teaching a client on prescribed dabigatran for chronic atrial fibrillation. Which statement by the client indicates a need for further teaching? 1. "I will call my health care provider if I notice red urine or blood in my stool." 2. "I will not stop taking dabigatran even if I get a stomachache." 3. "I will place capsules in my pill box so I will not forget to take a dose" 4. "I will swallow the capsule whole with a full glass of waler"

3. "I will place capsules in my pill box so I will not forget to take a dose"

The nurse is performing discharge teaching for the parents of a 4-year-old with heat faire. Which statement by the parents indicates the need for further teaching related to the administration of digoxin? 1. 'I our child vomits after a dose, we won't give a second one " 2. "Symptoms of nausea and vomiting should be reported to our heath care provider (HCP)." 3. We will hold the dose if our child's heart rate is above 90/min 4. "We will not mix the medication with other foods or liquids\*

3. We will hold the dose if our child's heart rate is above 90/min

The nurse is caring for a client on IV heparin infusion and oral warfarin. Current laboratory values indicate that the client's aPTT is 5 times the control value and the PT/INR Is 2 times the control value. What action does the nurse anticipate? 1. Clarify vegetable consumption with client 2. Decrease the heparin rate 3. Decrease the warfarin dose 4. Obtain an order for vitamin K injection

2. Decrease the heparin rate

The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering? Click on the exhibit for more information. **Exhibit** Blood pressure 148/84 mm Hg → 98/60 mm Hg 24-hour intake/output 1000/3000 mL Serum sodium 140 → 150 Serum potassium 4.2 → 3.5 Serum glucose 90 → 99 1. Furosemide 2. Glipizide 3. Levofloxacin 4. Potassium chloride

1. Furosemide

The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (VT) that is now resolved. Which of the following instructions should the nurse include to prevent the recurrence of DV? Select all that apply 1."Do not take car rides longer than 4 hours for at last 3-4 weeks.\* 2. "Drink plenty of fluids every day and limit caffeine and alcohol intake." 3. "Elevate legs on a footstool when sitting and dorsiflex the feet often\* 4. "Resume your walking program as soon as possible after getting homo." 5. "Sit in a cross-legged position for 5-10 minutes to improve circulation\*

2. "Drink plenty of fluids every day and limit caffeine and alcohol intake." 3. "Elevate legs on a footstool when sitting and dorsiflex the feet often\* 4. "Resume your walking program as soon as possible after getting homo."

A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which of the following statements regarding digoxin toxicity indicates that further teaching is needed? 1. "I must visit my health care provider (HCP) to check my drug levels." 2. "I should report to my HCP if I develop nausea and vomiting." 3. "I should tell my HCP if I feel my heart skip a beat.\* 4. "I will need to increase my potassium intake.\*

4. "I will need to increase my potassium intake."

The nurse admits a client who fell off a 20-ft (6-m) ladder. On arrival in the emergency department, the client is arousable but lethargic. What is the nurse's priority action? 1. Ask about client's chronic medical conditions 2. Assess for level and duration of pain 3. Obtain a Glasgow Coma Scale score 4. Perform a head-to-toe assessment

3. Obtain a Glasgow Coma Scale score

The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? Select all that apply. 1. Complete activities such as bathing and dressing as quickly as possible 2. Decrease the client's anxiety by limiting the number of choices offered 3. Redirect the client if agitated by asking for help with a task or going for a walk 4. Remember to interact with the client as an adult, regardless of childlike affect 5. Use open-ended questions when communicating with the client

2. Decrease the client's anxiety by limiting the number of choices offered 3. Redirect the client if agitated by asking for help with a task or going for a walk 4. Remember to interact with the client as an adult, regardless of childlike affect

The emergency department nurse assesses a client involved in a motor vehicle accident who sustained a coup-contrecoup head injury. Which assessment finding is consistent with injury to the occipital lobe? 1. Decreased rate and depth of respirations 2. Deficits in visual perception 3. Expressive aphasia 4. Inability to recognize touch

2. Deficits in visual perception

The nurse is providing discharge education for a postoperative client who had a partial laryngectomy for laryngeal cancer. The client is concerned because the health care provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate? 1. "I will ask the health care provider to explain the consequences of your procedure." 2. "This is a common complication that will require you to have a hearing test every year." 3. "This is a common complication; your health care provider will order a consult for the speech pathologist." 4. "This is the reason you are using a special swallowing technique when you eat and drink."

4. "This is the reason you are using a special swallowing technique when you eat and drink."

A newborn has a large myelomeningocele. What nursing intervention is priority? 1. Assess the anus for muscle tone 2. Cover the area with a sterile, moist dressing 3. Measure the occipital frontal circumference 4. Place the newborn supine with the head of the bed elevated

2. Cover the area with a sterile, moist dressing

The nurse is caring for a young adult who is considering becoming pregnant. The client expresses concern, stating,"One of my parents has Huntington disease, and I am afraid my child will get it." How should the nurse respond? 1. "Genetic counseling is recommended. You will receive a referral before you leave." 2. "Huntington disease inheritance requires both biological parents to carry the gene." 3. "There are other ways to grow your family. You should consider adoption." 4 "This disease occurs spontaneously and is not likely to affect your children."

1. "Genetic counseling is recommended. You will receive a referral before you leave."

When performing developmental screenings in the well-child clinic, the registered nurse understands that which child is at highest risk of developing autism spectrum disorder? 1. 2-year-old who has a vocabulary of 10 words 2. 3-year-old who received measles, mumps, and rubella immunization at age 1 year 3. 4-year-old whose 10-year-old sibling has the disorder 4. E-year-old whose parents were age 42 at the time of birth

3. 4-year-old whose 10-year-old sibling has the disorder

The health care provider prescribes a multivitamin regimen that includes thiamine for a client with a history of chronic alcohol abuse. The nurse is aware that thiamine is given to this client population for which purpose? 1. To lower the blood alcohol level 2. To prevent gross tremors 3. To prevent Wernicke encephalopathy 4. To treat seizures related to acute alcohol withdrawal

3. To prevent Wernicke encephalopathy

The nurse is planning care for an 8-year-old client with mild cognitive impairment who is hospitalized for diagnostic testing. Which of the following interventions are appropriate to include in the plan of care? Select all that apply. 1. Consistently assign the same nurse and unlicensed assistive personnel to care for the client 2. Give direct procedural education and explanations to the parent rather than the client 3. Provide appropriate toys based on developmental level rather than chronological age 4. Reinforce parental limit-setting measures for preventing self-injurious behavior 5. Use a picture board to facilitate communication and promote understanding of procedures

1. Consistently assign the same nurse and unlicensed assistive personnel to care for the client 3. Provide appropriate toys based on developmental level rather than chronological age 4. Reinforce parental limit-setting measures for preventing self-injurious behavior 5. Use a picture board to facilitate communication and promote understanding of procedures

A client with stroke symptoms has a blood pressure of 240/124 mm Hg. The nurse prepares the prescribed nicardipine intravenous (IV) infusion solution correctly to yield 0.1 mg/mL. The nurse then administers the initial prescription to infuse at 5 mg/hr by setting the infusion pump at 50 mL/hr. What is the nurse's priority action at this time? 1. Assess hourly urinary output (19%) 2. Increase pump setting to correct administration rate to 100 mL/hr 3. Keep systolic blood pressure above 170 mm Hg 4. Monitor for a widening QT interval

3. Keep systolic blood pressure above 170 mm Hg

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current Glasgow Coma Scale (GCS) score is a "10." Which client assessment is most important for the reporting nurse to include? 1. Belief that the current surroundings are a racetrack ( 2. GCS score was "11" one hour ago 3. Recent vital signs show blood pressure of 120/80 mm Hg and pulse of 82/min 4. Reported allergy to penicillin and vancomycin

2. GCS score was "11" one hour ago

The nurse is giving a presentation at a community health event. The nurse should provide which instruction on how to prevent botulism? 1. Boil water if unsure of its source 2. Discard canned food with a bulging end 3. Keep milk cold 4. Wash hands

2. Discard canned food with a bulging end

The emergency department triage nurse is assessing 4 pediatric clients. Which client is a priority for further diagnostic workup and definitive care? 1. 1-year-old with ventriculoperitoneal shunt who has "lethargy" andpulse of 78/min 2. 3-year-old with history of meningocele who has unilateral ear pain and urinary incontinence 3. 6-year-old with muscular dystrophy who has "flu-like" symptoms and temperature of 100.4 F (38 C) 48 year- old with history of cerebral palsy who has foot injury and spastic clonus (3%)

1. 1-year-old with ventriculoperitoneal shunt who has "lethargy" andpulse of 78/min

An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, the unlicensed assistive personnel (UAP) takes the client's vital signs, but when the UAP goes back to assist the client with a shower, the client curses at and tries to hit the UAP. Which of the following is the most appropriate response by the registered nurse? Click on the exhibit button for additional information. * *Exhibits:** Vitals - Temp: 98.7 F, BP 110/64, HR 92, RR 22, Oxygen Sat 90% RA 1. "I need to assess the client." 2. "It sounds like the client is not satisfied with the care provided. I'll see if we can make the client more comfortable." 3. "Just leave the client alone now and try âgain later." 4. "The client probably has dementia and is under a lot of stress with the change of environment."

1. "I need to assess the client."

The nurse is preparing teaching for a client with Parkinson disease. Which of the following techniques are appropriate when communicating with a client with Parkinson disease? Select all that apply. 1. Encourage the client to speak slowly and pause to take deep breaths periodically 2. Identify and promote the client's capabilities and strengths throughout the sessions 3. Provide client teaching during times of day when the client has the most energy 4. Reserve discussion of important or complex teaching for the client's caregiver 5. Schedule teaching sessions at times with low risk of rushing or interruptions

1. Encourage the client to speak slowly and pause to take deep breaths periodically 2. Identify and promote the client's capabilities and strengths throughout the sessions 3. Provide client teaching during times of day when the client has the most energy 5. Schedule teaching sessions at times with low risk of rushing or interruptions

A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next? 1. Administer atropine for bradycardia 2. Administer nifedipine for hypertension 3. Have CT scan performed to rule out an intracranial bleed 4. Perform hourly neurologic checks with Glasgow coma scale (GCS)

3. Have CT scan performed to rule out an intracranial bleed

A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency? 1. "I am very tired, and it's hard for me to keep my eyes open." 2. "I don't feel good, and I want to be seen." 3. "I have not taken my blood pressure medicine in over a week." 4. "I have the worst headache I've ever had in my life."

4. "I have the worst headache I've ever had in my life."

The clinic nurse is assessing a previously healthy 60-year-old client when the client says, "My hand has been shaking when I try to cut food. I did some research online. Could I have Parkinson's disease?" Which response from the nurse is the most helpful? 1. "It can't be Parkinson's disease because you aren't old enough." 2. "Make sure you tell the physician about your concerns." 3. "Parkinson's disease does not cause that kind of hand shaking." 4. "Tell me more about your symptoms. When did they start?"

4."Tell me more about your symptoms. When did they start?"

A client with a history of headaches is scheduled for a lumbar puncture to assess the cerebrospinal fluid pressure. The nurse is preparing the client for the procedure. Which statement by the client indicates a need for further teaching by the nurse? 1"I may feel a sharp pain that shoots to my leg, but it should pass soon." 2."I will go to the bathroom and try to urinate before the procedure." 3. "I will need to lie on my stomach during the procedure." 4"The physician will insert a needle between the bones in my lower spine."

3. "I will need to lie on my stomach during the procedure."

The nurse educates the caregiver of a client with Alzheimer disease about maintaining the client's safety. Current symptoms include occasional confusion and wandering. Which of the following responses by the caregiver show correct understanding? Select all that apply. 1. "Grab bars should be installed in the shower and beside the toilet." 2. "I will place a safe return bracelet on the client's wrist." 3."Keyed deadbolts should be placed on all exterior doors." 4. "Medications will be placed in a weekly pill dispenser." 5."Throw rugs and clutter will be removed from the floors."

1. "Grab bars should be installed in the shower and beside the toilet." 2. "I will place a safe return bracelet on the client's wrist." 3. "Keyed deadbolts should be placed on all exterior doors." 5. "Throw rugs and clutter will be removed from the floors."

A child is scheduled to have an electroencephalogram (EEG). Which statement by the parent indicates understanding of the teaching? 1. "I will let my child drink cocoa as usual the morning of the procedure." 2. "I will wash my child's hair using shampoo the morning of the procedure." 3. "My child may have scalp tenderness where the electrodes were applied." 4. "My child will not remember the procedure."

2. "I will wash my child's hair using shampoo the morning of the procedure."

A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first? 1. Administer rectal diazepam 2. Assess for neck stiffness and Brudzinski sign 3. Draw blood for laboratory studies 4. Transport the client to CT for assessment of shunt malfunction

1. Administer rectal diazepam

The nurse is caring for a client following a transsphenoidal hypophysectomy. Which clinical findings would the nurse recognize as signs that the client may be developing diabetes insipidus? Select all that apply. 1. Decreased serum sodium 2. Excess oral water intake 3. High urine output 4. Increased serum osmolality 5. Increased urine specific gravity

2. Excess oral water intake 3. High urine output 4. Increased serum osmolality

The emergency department nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment? 1. History of Bell's palsy with unilateral facial droop and drooling 2. History of multiple sclerosis and reporting recent blurred vision 3. Reports unilateral facial pain when consuming hot foods 4. Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14

4. Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14

A nurse is teaching the parent of an 8-month-old infant who had a febrile seizure about management of future fevers. Which instruction is appropriate to include in the teaching? 1."Give acetaminophen or ibuprofen every 6 hours to control the fever." 2."Give the infant frequent tepid sponge baths to control the fever." 3."If the infant develops another seizure, wait 15 minutes to see if it subsides." 4."Place ice bags under the arms and around the neck to reduce the fever."

1."Give acetaminophen or ibuprofen every 6 hours to control the fever."

The nurse is caring for a client who had a stroke two weeks ago and has moderate receptive aphasia. Which interventions should the nurse include in the plan of care to help the client follow simple commands regarding activities of daily living (ADL)? Select all that apply. 1. Ask simple questions that require "yes" or "no" answers 2. If the client becomes frustrated, seek a different care provider to complete ADL 3. Remain calm and allow the client time to understand each instruction 4. Show the client pictures of ADL (eg, shower, toilet, and toothbrush) or use gestures 5. Speak slowly but loudly while looking directly at the client

1. Ask simple questions that require "yes" or "no" answers 3. Remain calm and allow the client time to understand each instruction 4. Show the client pictures of ADL (eg, shower, toilet, and toothbrush) or use gestures

A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. Which priority interventions should the nurse perform? Select all that apply 1. Administer an analgesic as needed 2. Determine if there is bladder distention 3. Measure the client's blood pressure 4. Place the client in the Sims' position 5. Remove constrictive clothing

2. Determine if there is bladder distention 3. Measure the client's blood pressure 5. Remove constrictive clothing

The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension. What is most important for the nurse to emphasize to prevent a stroke (acute brain attack)? 1. Consume a low-fat, low-salt diet 2. Do not smoke cigarettes 3. Exercise and lose weight 4. Take prescribed antihypertensive medications

4. Take prescribed antihypertensive medications

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is \>200 mm Hg. Which action by the nurse is most appropriate? 1. Give the antihypertensive medication 2. Monitor the blood pressure 3. Notify the health care provider 4. Question the prescription

2. Monitor the blood pressure

The nurse is caring for a client with absence seizures. The unlicensed assistive personnel (UP) asks if the client will "shake and jerk" when having a seizure. Which response from the nurse is the most helpful? 1. "No, absence seizures can look like daydreaming or staring off into space." 2. "No, you are wrong. Don't worry about that." 3. "Yes, so please let me know if you see the client do that." 4. "You don't have to monitor the client for seizures."

1. "No, absence seizures can look like daydreaming or staring off into space."

3. To prevent Wernicke encephalopathy

The nurse is caring for a client who is taking riluzole for amyotrophic lateral sclerosis (ALS). The client asks, "There's no cure for ALS, so why should I keep taking this expensive drug?" What is the nurse's best response? 1. "It may be able to slow the progression of ALS." 2. "It reduces the amount of glutamate in your brain." 3. "The case manager may be able to find a program 4. "You have the right to refuse the medication."

1. "It may be able to slow the progression of ALS."

The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do? 1. Bend at the waist 2. Keep the feet close together 3. Pivot on the foot proximal to the chair 4. Use a transfer belt

4. Use a transfer belt

The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin. Which of the following should the nurse include in client teaching? Select all that apply. 1. "Avoid drinking alcoholic beverages." 2. "Do not abruptly stop taking your phenytoin." 3. "Go to the emergency department every time a seizure occurs." 4 "Wear an epilepsy medical identification bracelet." 5. "You may need to start using a nonhormonal birth control method."

1. "Avoid drinking alcoholic beverages." 2. "Do not abruptly stop taking your phenytoin." 4 "Wear an epilepsy medical identification bracelet." 5. "You may need to start using a nonhormonal birth control method."

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider? 1. "I got short of breath this morning when I worked out." 2. "I have cut down on smoking to 1/2 pack per day." 3. "| haven't been feeling well, so I have been sleeping a lot." 4. "I took an acetaminophen in the waiting room for this bad headache."

4. "I took an acetaminophen in the waiting room for this bad headache."

The nurse receives report for 4 clients in the emergency department. Which client should be seen first? 1. 30-year-old with a spinal cord injury at L3 sustained in a motor cycle accident who reports lower abdominal pain and difficulty urinating 2. 33-year-old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait 3. 65-year-old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 mL 4. 70-year-old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL

4. 70-year-old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL

The nurse is caring for a client with a history of tonic-clonic seizures. After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes. The client does not know the current location, does not know the current season, and has a headache. The nurse documents the confusion and headache as which phase of the client's seizure activity? 1. Aural phase 2. Ictal phase 3. Postictal phase 4. Pindromal phase

3. Postictal phase

A client is admitted to the ambulatory care unit for an endoscopic procedure. The gastroenterologist administers midazolam1 mg intravenously for sedation and titrates the dosage upward to 3.5 mg. The client becomes hypotensive (86/60 mm Hg), develops severe respiratory depression (SpO2 86%), and has periods of apnea. The nurse anticipates the administration of which antidote drug? 1. Benztropine 2. Flumazenil 3. Naloxone 4. Phentolamine

2. Flumazenil

A nurse is teaching the parent of a child who has a new diagnosis of absence seizures. Which statement by the parent indicates understanding of the teaching? 1. "My child may experience incontinence." 2. "My child may seem confused afterwards." 3. "My child may stare and seem inattentive." 4. "My child will notice unusual odors prior to the event."

3. "My child may stare and seem inattentive."

The nurse is caring for a client who has homonymous hemianopsia following an acute stroke. Which nursing diagnosis is the most appropriate for this client? 1. Risk for ineffective airway maintenance 2. Risk for knowledge deficit 3. Risk for poor fluid intake 4. Risk for self-neglect

4. Risk for self-neglect

During the shift report it was noted that the off-going nurse had given the client a PRN dose of morphine 2 mg every 2 hours for incisional pain. What current client assessment would most likely affect the oncoming nurse's decision to discontinue the administration every 2 hours? 1. Client reports burning during injection into the IV line 2. Client reports dizziness when getting up to use the bathroom 3. Client's blood pressure is 106/68 mm Hg 4. Client's respiratory rate is 11/min

4. Client's respiratory rate is 11/min

The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent gastrointestinal (Gl) illness. Monitoring for which of the following is a nursing care priority for this client? 1. Diaphoresis with facial flushing 2. Hypoactive or absent bowel sounds 3. Inability to cough or lift the head 4. Warm, tender, and swollen leg

3. Inability to cough or lift the head

A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits? Select all that apply. 1. Identify the number "8" traced on the palm 2. Shrug the shoulders against resistance 3. Swallow water 4. Touch each finger of one hand to the hand's thumb 5. Walk heel-to-toe

4. Touch each finger of one hand to the hand's thumb 5. Walk heel-to-toe

The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin. Which of the following should the nurse include in client teaching? Select all that apply. 1. "Avoid drinking alcoholic beverages." 2. "Do not abruptly stop taking your phenytoin." 3. "Go to the emergency department every time a seizure occurs." 4. "Wear an epilepsy medical identification bracelet." 5. "You may need to start using a non hormonal birth control method."

1. "Avoid drinking alcoholic beverages." 2. "Do not abruptly stop taking your phenytoin." 4. "Wear an epilepsy medical identification bracelet." 5. "You may need to start using a non hormonal birth control method."

The nurse is assessing the cranial nerves and begins testing the facial nerve (cranial nerve VII). Which direction should the nurse give the client to test this cranial nerve? 1. "Close your eyes and identify this smell." 2. "Follow my finger with your eyes without moving your head." 3. "Look straight ahead and let me know when you can see my finger." 4. "Raise your eyebrows, smile, and frown."

4. "Raise your eyebrows, smile, and frown."

4. Use a transfer belt

A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider. Which intervention does the nurse add to this client's care plan? 1. Encourage client to drink cold beverages 2. Encourage client to eat a high-fiber diet 3. Encourage client to perform facial massage 4. Encourage client to report any fever or sore throat

4. Encourage client to report any fever or sore throat

The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential complication during hospitalization? Select all that apply. 1. Add a thickening agent to the fluids 2. Avoid administering sedating medications before meals 3. Place the client in an upright position during meals 4. Restrict visitors who show signs of illness 5. Teach the client to flex the neck while swallowing

1. Add a thickening agent to the fluids 2. Avoid administering sedating medications before meals 3. Place the client in an upright position during meals 5. Teach the client to flex the neck while swallowing

A7-month-old infant is admitted to the unit with suspected bacterial meningitis after receiving an initial dose of antibiotics in the emergency department. Frequent assessment of which of the following is most important in the plan of care? 1. Babinski reflex 2. Fontanel assessment 3. Pulse pressure 4. Pupillary light response

2. Fontanel assessment

A client with multiple sclerosis is voicing concerns to the nurse about incoordination when walking. Which of the following instructions by the nurse would be most appropriate at this time? 1. "Avoid excess stretching of your lower extremities." 2. "Build strength by increasing the duration of daily exercise." 3. "Let me speak with your health care provider about getting a wheelchair." 4. "You should keep your feet apart and use a cane when walking."

4. "You should keep your feet apart and use a cane when walking."

The nurse is caring for a client who is taking riluzole for amyotrophic lateral sclerosis (ALS). The client asks, "There's no cure for ALS so why should I keep taking this expensive drug?" What is the nurse's best response? 1. "It may be able to slow the progression of ALS." 2. "It reduces the amount of glutamate in your brain." 3. "The case manager may be able to find a program to assist with cost." 4. "You have the right to refuse the medication."

1. "It may be able to slow the progression of ALS."

A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted? 1. Improvement in short-term memory 2. Improvement in spontaneous activity 3. Reduction in number of visual hallucinations 4. Reduction of dizziness with standing

2. Improvement in spontaneous activity

A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially? 1. Administer PRN analgesic medication 2. Administer PRN antihypertensive medication 3. Lower the head of the bed 4. Palpate the client's bladder

4. Palpate the client's bladder

The nurse is caring for a client with increased intracranial pressure (ICP). Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse? 1. "I will raise the head of the bed so it is easier to see the television." 2. "I will turn down the lights when I leave." 3. "Let me move your belongings closer so you can reach them." 4. "You should do deep breathing and coughing exercises."

4. "You should do deep breathing and coughing exercises."

The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the health care provider? 1."I am feeling unsteady when I walk." 2. "I am getting up to urinate about 4 times during the night." 3. "I have a metallic taste in my mouth when I eat." 4. "My gums are getting so puffy and red."

1."I am feeling unsteady when I walk."

A client was prescribed phenytoin (100 mg PO 3 times a day) a month ago. Today, the client has a serum phenytoin level of 32 mcg/mL (127 mcmol/L). The nurse notifies the health care provider and expects which prescription? 1. Continue phenytoin as prescribed 2. Decrease phenytoin daily dose 3. Increase phenytoin daily dose 4. Repeat serum phenytoin level in 2 hours

2. Decrease phenytoin daily dose

The health care provider (HCP) has prescribed amitriptyline 25 mg orally every morning for an elderly client with recent herpes zoster infection (shingles) and severe postherpetic neuralgia. What is the priority nursing action? 1. Encourage increased fluid intake 2. Provide frequent rest periods 3. Teach the client to get up slowly from the bed or a sitting position 4. Tell the client to wear sunglasses when outdoors

3. Teach the client to get up slowly from the bed or a sitting position

The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant healthcare provider notification? 1. "I am going for repeat testing to confirm glaucoma." 2. "I am not able to exercise as much as I used to." 3. "I started taking esomeprazole for heartburn." 4. "My bowel movements are not regular."

1. "I am going for repeat testing to confirm glaucoma."

The nurse reviews the laboratory results of several clients. Which finding should the nurse report to the healthcare provider immediately? 1. Client who is receiving tube feedings and has a phenytoin level of 8 mcg/mL (32 momol/L) 2. Client with a heart rate of 62/min who has a digoxin level of 1.3 ng/mL (1.7 mol/L) 3. Client with a new prosthetic aortic valve who has an INR of 3.0 4. Client with a poor appetite and a lithium level of 0.8 mEq/L (0.8 mmol/L)

1. Client who is receiving tube feedings and has a phenytoin level of 8 mcg/mL (32 momol/L)

A hospitalized client develops acute hemorrhagic stroke and is transferred to the intensive care unit. Which nursing interventions should be included in the plan of care? Select all that apply. 1. Administer PRN stool softeners daily 2. Administer scheduled enoxaparin injection 3. Implement seizure precautions 4. Keep client NP until swallow screen is performed 5. Perform frequent neurological assessments

1. Administer PRN stool softeners daily 3. Implement seizure precautions 4. Keep client NP until swallow screen is performed 5. Perform frequent neurological assessments

A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response? 1. "It destroys tumor cells and helps shrink the tumor." 2. "It prevents seizure development." 3. "It prevents blood clots in legs." 4. "It reduces swelling around the tumor."

2. "It prevents seizure development."

The nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes. Which cranial nerves is the nurse assessing? Select all that apply. 1. II 2. II 3. IV 4. V 5. VI

2. II 3. IV 5. VI

The emergency department nurse is assessing a client brought in after a car accident in which the client's head hit the steering column. Which assessment findings would indicate that the triage nurse should apply spinal immobilization? Select all that apply. 1. Breath smells of alcohol \*\* 2. Client disoriented to place\*\* 5. Point tenderness over spine \*

The nurse is reviewing new prescriptions for assigned clients. Which prescription would require further clarification from the healthcare provider? 1. Alteplase for an ischemic stroke in a client with a blood pressure of 192/112 mm Hg 2. Amoxicillin for a respiratory infection in a client who is 20 weeks pregnant 3. Fentanyl for moderate to severe pain in a client post appendectomy with an allergy to codeine 4. Sodium chloride 3% infusion for a client with syndrome of inappropriate antidiuretic hormone

1. Alteplase for an ischemic stroke in a client with a blood pressure of 192/112 mm Hg

The clinic nurse prepares to administer a newly prescribed dose of sumatriptan to a client with a migraine headache. Which item in the client's history would cause the nurse to question the prescription? 1. Blood urea nitrogen of 12 mg/dL (4.28 mmol/L) 2. BMI of 34 kg/m? recorded during today's examination 3. Past medical history of uncontrolled hypertension 4. Takes alprazolam as prescribed for anxiety

3. Past medical history of uncontrolled hypertension

The office nurse, while reviewing a client's health information, notices that the client has recently started taking St. John's wort for symptoms of depression. What additional information is most important for the nurse to obtain? 1. Ask if the client is currently taking any prescription antidepressant medications 2. Ask if the client has been diagnosed with depression by a mental health care provider (HP) 3. Ask if the client takes a multivitamin with iron 4. Ask if the client uses tanning beds

1. Ask if the client is currently taking any prescription antidepressant medications

A client with seizure activity is receiving a continuous tube feeding via a small-bore enteral tube. The nurse prepares to administer phenytoin oral suspension via the enteral route. What is the nurse's priority action before administering this medication? 1. Check renal function laboratory results 2. Flush tube with normal saline, not water 3. Stop the feeding for 1 to 2 hours 4. Take the blood pressure (BP)

3. Stop the feeding for 1 to 2 hours

The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time? 1. Client admitted with Guillain-Barré syndrome yesterday is paralyzed to the knees 2. Client admitted with multiple sclerosis exacerbation has scanning speech 3. Client with epilepsy puts on call light and reports having an aura 4. Client with fibromyalgia reports pain in the neck and shoulders

3. Client with epilepsy puts on call light and reports having an aura

A client with seizure disorder is prescribed a moderately high dose of phenytoin. Which teaching topic should the nurse discuss with this client? 1. Diet high in iron 2. Good oral care and dental follow-up 3. Shaving with an electric razor 4. Use of sunglasses for eye protection

2. Good oral care and dental follow-up

The clinic nurse is instructing a client who is newly prescribed transdermal scopolamine to prevent motion sickness during an upcoming vacation on a cruise ship. Which of the following statements made by the nurse are appropriate? Select all that apply. 1. "Apply the patch when the ship starts moving and not before." 2. "Dispose of the patch out of reach of children and pets." 3. "Make sure to remove the old patch before applying a new one." 4. "Place the patch on a hairless, clean, dry area behind the ear." 5. "Wash your hands with soap and water after handling the patch.

2. "Dispose of the patch out of reach of children and pets." 3. "Make sure to remove the old patch before applying a new one." 4. "Place the patch on a hairless, clean, dry area behind the ear." 5. "Wash your hands with soap and water after handling the patch.

A client with Parkinson disease is prescribed carbidopa-levodopa. Which of the following instructions should the nurse include with the client's discharge teaching? Select all that apply. 1 "Change positions slowly, and sit on the side of the bed before standing." 2. "This medication takes several weeks to reach maximum benefit.” 3. "You may experience some facial and eye twitching, but this is not harmful." 4. "Your tremors should disappear completely while on this medication." 5."Your urine and saliva may turn reddish-brown, but this is not harmful."

1 "Change positions slowly, and sit on the side of the bed before standing." 2. "This medication takes several weeks to reach maximum benefit.” 3. "You may experience some facial and eye twitching, but this is not harmful." 5. "Your urine and saliva may turn reddish-brown, but this is not harmful."

The nurse reviews the analgesia prescriptions for assigned clients. The nurse should question the healthcare provider about which prescription? 1. Lidocaine 5% patch over intact skin for a client with chronic postherpetic neuralgia who reports intolerable, persistent, burning pain 2. Hydromorphone IV for a client who has a fractured femur, is a known IV heroin abuser, and rates pain as 9 on a 0-10 scale 3. Tramadol for a client who is being prepared for discharge following a laparoscopic cholecystectomy and rates abdominal pain as 6 on a 0-10 scale 4. Transdermal fentanyl patch for a client who is 1 day postoperative above-the-knee amputation and reports intermittent, throbbing stump pain

4. Transdermal fentanyl patch for a client who is 1 day postoperative above-the-knee amputation and reports intermittent, throbbing stump pain

The nurse is reinforcing education to a client newly prescribed levetiracetam for seizures. Which statement made by the client indicates a need for further instruction? 1. "Drowsiness is a common side effect of this medication and will improve over time." 2. "I can begin driving again after I have been on this medication for a few weeks." 3. "I need to immediately report any new or increased anxiety when on this medication." 4. "I need to immediately report any new rash when on this medication."

2. "I can begin driving again after I have been on this medication for a few weeks."

The nurse in the same-day surgery unit admits a client who will receive general anesthesia. The client has never had surgery before. Which question is most critical for the nurse to ask the client during the preoperative assessment and health history? 1. "Has any family member ever had a bad reaction to general anesthesia?" 2. "Have you ever experienced low back pain?" 3. "Have you ever had an anaphylactic reaction to a bee sting?" 4. "Have you ever received opioid pain medications?"

1. "Has any family member ever had a bad reaction to general anesthesia?"

A nurse is preparing for a medical relief trip to West Africa and is concerned about a disruption in circadian rhythm from traveling across several time zones. Which herbal supplement might help synchronize the body to environmental time? 1. Evening primrose 2. Ginseng 3. Melatonin 4. St. John's wort

3. Melatonin

A client having an ischemic stroke arrives at the emergency department. The health care provider prescribes tissue plasminogen activator (PA). Which client statement would be most important to clarify before administering tPA? 1. "I can't believe this is happening right after my stomach surgery." 2. "I had a concussion after a car accident a year ago." 3. "I started noticing my right arm becoming weak approximately an hour ago. 4. "I stopped taking my warfarin 4 weeks ago."

1. "I can't believe this is happening right after my stomach surgery."