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Exam 3 MS
| Question | Answer |
|---|---|
| the nurse caring for a client with a new tracheotomy which assessment finding requires the nurses immediate action? | assess for subcutaneous emphysema |
| the nurse assesses the client receiving 60% oxygen via tracheostomy collar, which assessment finding requires immediate action by the nurse? | constant non productive cough |
| the client has been placed on 6L humidified o2 via nasal cannula, what will be the highest priority action of the nurse? | removing condensation tubing by disconnecting and emptying into trash can |
| a client is being discharged with a tracheostomy and voices concern about appearance, what discharge teaching will assist the client with maintaining positive body image? | your clothing can hide the tracheotomy so it is as not noticeable |
| the client is becoming frustrated because of his inability to communicate while he has a tracheotomy which intervention by the nurse will most effectively enhance his ability to communicate? | providing a communication board and keep the call bell within reach |
| the nurse enters the room of a client who has a tracheotomy and finds a visitor in the room speaking loudly to the client, the client appears to be angry and frustrated, which intervention should the nurse implement to address the problem? | the nurse should tactfully tell the visitor to remind that the clients comprehension has not been effected only his ability to speak |
| the client requires oxygen using a face mask but wants to remain as mobile as possible once he is discharged home, which intervention by the home health nurse will best provide the client with maximal mobility? | add extra pieces of tubing to the client existing oxygen set up |
| client diagnosed lung disease & placed on 2L nasal oxygen while hospitalized the client has been on o2 for appx. 30 min suddenly seems even more SOB he is neither gray or ashy the nurse recognizes that the client is experienced in which of the following | oxygen induced hypoventilation |
| which manifestations in a client receiving oxygen therapy at 60 % for more than 24 hours would alert the nurse to possibility of o2 toxicity? | increase dyspnea |
| a client receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. what the nurse do first? | assess pulse oximetrey |
| the nurse assesses the client receiving oxygen via partial rebreather mask, the nurse will intervene for which assessment finding? | oxygen flow rate is at 2 L |
| a client is to be discharged to home on oxygen therapy what information will the nurse teach the client? | the d and c cylinder can be carried |
| the nurse assesses the client with a new tracheotomy and the new tracheotomy tube is pulsating in sync with the clients heartbeat. what is the nurses priority action? | call the physician |
| the client is 24 hours postoperative after tracheotomy has been performed, the nurse finds the client cyanotic with with a tracheotomy tube lying on his chest, what is the nurses first action? | ventilate with resuscitation bag with mask and at the same time call for help |
| while suctioning the client who has a tracheostomy placed 4 days ago, the nurse notes particles of food and tracheal secretions, what is the nurses priority action? | perform a more thorough assessment |
| the nurse is teaching the client about his fenestrated tracheotomy tube which statement by the client indicates an accurate understanding of the tube? | im glad i will still be able to talk with this tube in place |
| the nurse observes the nursing student suctioning the client which intervention on the nursing student has the greatest potential to cause tissue damage? | applying suction when the catheter is inserted |
| the nurse assess the client during suctioning, which finding indicates that the procedure should be stopped? | the heart decreases from 70 to 40 |
| which action is highest priority for the nurse to teach the client with a tracheotomy to decrease the risk for aspirations? | thicken all liquids |
| the nurse is assessing the client with chronic lung disease on 6 L of o2 via nasal cannula, which finding indicate a potential acute problem? | respiratory rate of 6 |
| which statement by the client indicates that he has an accurate understanding of home self care of his tracheotomy? | i need to keep water from entering the airway |
| the client is being weaned from his tracheotomy tube and has tolerated the tubing cap for 24 hrs, which of the following should be the highest priority on the part of the nurse? | placing the dry dressing over the stoma and secure it in place |
| the client tells the nurse that she feels shy going out in public places with her tracheotomy, which of the following should be the highest priority action on the part of the nurse? | help the client drape attractive scarves so the tracheotomy is hidden |
| which statement by the client's family member indicates a accurate understanding of the correct way to provide the client with mouth care while he has a tracheotomy? | i clean his mouth water and a toothette |
| the nurse is teaching the family member how to suction the clients tracheotomy at home, which of the following should be the highest priority action on the nurse to teach the family member? | suction using clean technique |
| the client is experiencing acute rhinitis which intervention is most important for the nurse to include in the clients plan of care? | monitor for drug effects such as vertigo hypertension urinary retention and insomnia |
| which is the highest priority teaching need for a client with sinusitis? | increase fluid intake |
| the nurse is caring for a client with recurrent bacterial pharyngitis, which is the nurses highest priority intervention? | verify that the client understands the importance of completing the entire antibiotic prescription |
| what is essential for the nurse to teach the client who is believed to to have developed pneumonia about using a nebulizer at home? | assess whether the clients home cleaning level nebulizer is adequate |
| which should be the priority intervention of the teaching plan to instruct a client about the proper use of an incentive spirometer? | instruct the client to exhale and take a breath for 5-10 seconds |
| which statement indicates the nurse understands the spread of severe acute respiratory syndrome SARS? | I will use airborne and contact precautions when I am in contact with the client |
| which statement is correct about the care of the client with Avian influenza? | the client will be placed on airborne contact isolation and will receive oxygen |
| which statement by the nurse indicates an accurate understanding of TB as a disease process? | the client can have a negative skin test if he is immunocompromised |
| the nurse is instructing a group of new nurses on the ventilator bundle approach to the prevention of ventilator associated pneumonia, which intervention is emphasized in this approach? | continuously remove subglottic secretions |
| which is the nurses best response when a client ask how the common cold is transmitted? | the cold can be spread by droplets from sneezing and coughing through secretions |
| which client will caution to avoid taking over the counter decongestants for manifestations of a cold or flu? | a middle age woman with hypertension |
| the client has a recurrences of a Streptococcal infection, which additional assessment would be performed so the nurse can assess for complications? | Urinalysis |
| what is the priority action to teach a client to prevent the spread of colds? | washing your hands after blowing your nose and sneezing |
| an older client was prescribed a antihistamine which medical problem may be aggravated by this medication? | urinary retention |
| which client's statement alert the nurse the possibility of rhinitis mediacamentosa? | my nose doesn't stay open even though i use nasal spray every hour |
| which intervention will the nurse include in discharge teaching after sinus surgery to prevent bleeding from the surgical site? | use a stool softener |
| the client has a peristonsillar abscess which is the priority instruction the nurse will provide to this client? | take the antibiotic for the entire time it is prescribed not just until you feel better |
| which client statement indicates a need for clarification regarding the cause and treatment of acute laryngitis? | i suck on lozenges to keep my mouth and throat from getting so dry |
| an older adult client with heart failure asks when she should get a flu shot, which is the nurses best response? | get a flu shot in the early fall so you can make enough antibodies before flu season arrives |
| which assessment finding alerts the nurse to the possibilities of pneumonia in the client with chronic bronchitis? | percussion is dull in the left lower lobe |
| which person is at greater risk for developing a community acquired pneumonia? | an older adult who smokes and has a substance abuse problem |
| the nurses assesses which client for nosocomial pneumonia? | the client receiving mechanical ventilation |
| which is the nurses best response to an older adult client who is hesitant to take the pneumococcal vaccination in the same year? | the flu shot may protect you against influenza but won't protect against bacteria that causes pneumonia |
| which is a priority teaching intervention for the client who is using a nicotine patch? | smoking while using this patch increases the risk of heart attack |
| the client with TB asks his nurse when he will be considered non infectious. which is the nurses best response? | when you have 3 negative sputum cultures 3 in a row |
| the client has a productive cough fever chills and history of night sweats, the clients ppd test is negative which is the nurses best intervention related to infection prevention? | using standard and airborne precautions until a chest xray shows no evidence of TB |
| A nurse is reading a ppd test on the left arm of an inpatient client who was admitted 48 hrs ago, the area has a 4 mm diameter area of induration, which is the nurses best action? | reexamine the test site in 72 hours |
| which assessment finding alerts the nurse to the possibility of pleura effusion and emphysema? | bbsences of fremitus at on below the site on injury |
| the client with manifestations of respiratory infection is suspected of inhalation anthrax. in addition to standard precaution which other infection could control precautions will the nurse use until the diagnosis is certain. | No addition precautions, inhalation anthrax does not spread by person to person contact |
| the client who is exposed to inhalation anthrax has completed drug therapy with ciprofloxicin because he has no manifestations he would like to stop taking the drug. | you need to take it for 60 days it may take 8 weeks for symptoms to appear |
| what is the effect on the clients hormone response to a naturally occurring hormone if the client takes a drug that blocks the hormone receptor site. | it would decrease the hormone activity |
| how does the tropic hormone differ from other hormones? | a tropic hormones stimulate other endocrine glands to secrete hormones |
| which will the nurse assess next in a male client who begins to have fluid secretions from his breast? | anterior pituitary hormones |
| the client is receiving 300 mg of morphine daily for severe pain, which is the nurses priority intervention? | measuring input and output |
| which affects does the nurse expect daily cortisol therapy to have on client circulating client levels ACTH and aldosterone? | decrease acth and decrease aldosterone |
| which is the clinical manifestation for a client who has excessive production of the melanocytes stimulating hormone? | darkening of the skin |
| which assessment finding in client taking a drug that stimulate beta 1 receptors requires immediate action of the nurse? | pulse rate 50 bpm |
| the client has been diagnosed with addison's disease, his wife ask the nurse if he can be developing Alzheimer's disease because he is exhibiting memory loss. which is the most accurate response from the nurse? | forgetfulness is symptom of addison's disease i will tell your doctor you are concerned |
| the client is scheduled to being treatment with androgen replacement and has a concern about self administration because of his arthritis how will the nurse suggest that this medication be ordered? | Transdermal patch |
| the client expresses some concern that the drug prescribed prior to endocrine testing is to be taken during the night, how will the nurse best advised the client? | setting an alarm and take the drug at a scheduled time |
| the client has a hormone deficiency which deficiency is the highest priority? | Thyroid stimulating hormone |
| which safety measure will the nurse use who has growth hormone deficiency? | using a lift sheet to reposition the client |
| the male client has hyperpituitarism and asks the nurse how long he will have to take testosterone therapy. which is the nurses best response? | it is life long |
| the client thought to have a problem with the pituitary gland is giving 25 units of regular insulin a short time later a blood analysis reveals of growth hormone and ACTH. Which is the nurses interpretation of this finding? | The client has a normal pituitary response to insulin |
| the family of a client with SIADH asks the nurse if the water restriction is a punishment for the clients uncooperative behavior, which is the nurses best response? | limiting fluid intake keeps urine from becoming diluted |
| which safety measure is most important for the nurse to initiate for a client who has cushing's disease? | using a lift sheet |
| which dietary alterations will the nurse make for the client with cushings disease? | low carbohydrate, high calorie and low sodium |
| the client has received vasopressin for diabetes insipidus, which assessment finding indicates a therapeutic response to therapy? | urine output is decreased and specific gravity is increased |
| which client statement indicates a need for further clarification regarding medications after a bilateral adrenalectomy? | if I have nausea and vomiting I will skip the medication until it resolves |
| the client has chronic hypercortisolism which intervention is highest priority for the nurse? | washing hands when entering the room |
| a client present with elevation in T3 and T4 and decrease in TSH levels which is the nurses priority intervention? | monitor the apical pulse |
| which dietary modifications will the nurse provide with client with hyperhyroidism? | increase calories, proteins and carbs |
| which patient would not be to have radioactive iodine therapy? | pregnant women |
| the client with hyperthyroidism is taking lithium carbonate. which findings indicate that the client is having side effects of this therapy? | lithium increases thirst and urination |
| 12 hrs after a thyroidectomy, client develops stridor on exhalation. which is the nurses priority intervention? | calling for emergency assistance |
| which is a priority nursing diagnosis for a client with hypothyroidism? | disturbed through process |
| client has hypothyroidism as a result hashitomotos thyroidits asks the nurse how long will they have to take thyroid medication, what is the nurses best response? | you'll have thyroid replacement therapy for life because the gland function will not return |
| which client intervention will the nurse use to prevent injury in a client with hyperparathryoidism? | use a lift sheet |
| when taking the blood pressure of a client after a parathyroidectomy, the nurse notices the clients hands has gone into flexion contractions. what does the nurse deteremine may be the cause of this symptom? | hypocalemia |
| which alteration in vital signs is most indicative of hypothyroidism? | apical rate of 50 bpm |
| when fecal urobilinogen concentration levels are decreased as result of biliary cirhosis the stool becomes lighter or clay colored. | clay colored stools |
| the nurse recognizes that fector hepaticus is consistent with which assessment finding? | fruit or musty breath odor |
| for the client with cirrhosis which nursing intervention would be most effective in fluid accumulation in the abdominal cavity? | providing a low sodium diet |
| which clinical finding does the nurse expect to find observe in a client who has just undergone peritoneal shunt replacement? | increase blood pressure |
| the client with obstructive jaundice asks why his skin is so itchy. what is the nurses best response? | itching is caused by accumulation of bile salts on the skin |
| nurse caring for a client with cholecystitis. which alerts the nurse the condition chronic rather than acute? | the client has clay colored stools and amber urine |
| the nurse is providing discharge teaching for a client who has undergone laparoscopic cholesytectomy surgery, which statement of the client indicates understanding of the instructions? | I will have small low fat meals |
| the nurse is caring for a client who has undergone a traditional cholesytectomy surgery, the drain is in place, the nurse notes that there is serousanguines drainage is present in the drain, which is the nurses priority action? | documenting the findings in the clients chart |
| the nurse is caring for a postoperative client, the clients complains of pain shoulder blades are in following laparoscopic cholecystectomy surgery. which direction will the nurse give to the nursing assistant to help relieve the clients pain? | ambulate the client in the hallway |
| during a physical assessment the nots the presence of turners sign which is the nurses priority action? | ensuring the client has a patent large bore IV site |
| the nurse is caring for a client with chronic pancreatitis, which statement by the client indicates additional teaching is needed? | i will avoid simple carbohydrates and concentrated sweets |
| the nurse is caring for a client who has been just diagnosed with end state pancreatic cancer. the nurse assess the clients emotional response to the diagnosis. which is the nurses initial action for assessment? | determine if the client feels like talking about his or her feelings |
| the nurse is caring for a client that just underwent the whipple procedure two days previously. the nurse notes that the clients hands and feet are edematous and urine output is decreased from the previous day, which intervention will the nurse expect to | Adding additional amino acids to the clients tpn solution |
| the nurse is caring for a client with acute pancreatitis. the client is receiving bental 20 mg im 16h which assessment finding leads the nurse to clarify with the clients physician? | the nurse does not hear any bowel sounds in the clients abdomen |
| what is the effect of a clients hormone response to a naturally occurring hormone if the client takes a drug that blocks that hormone receptor site. | decreases it |
| which effect does the nurse expect daily cortisol therapy to have on clients circulatory levels of acth and aldosterone. | decrease aldosterone and acth |
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infamousjiggz
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