question

the nurse caring for a client with a new tracheotomy which assessment finding requires the nurses immediate action

answer

assess for subcutaneous emphysema

question

the nurse assesses the client receiving 60% oxygen via tracheostomy collar, which assessment finding requires immediate action by the nurse

answer

constant non productive cough

question

the client has been placed on 6L humidified o2 via nasal cannula, what will be the highest priority action of the nurse

answer

removing condensation tubing by disconnecting and emptying into trash can

question

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

answer

your clothing can hide the tracheotomy so it is as not noticeable

question

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

answer

providing a communication board and keep the call bell within reach

question

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

answer

the nurse should tactfully tell the visitor to remind that the clients comprehension has not been effected only his ability to speak

question

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

answer

add extra pieces of tubing to the client existing oxygen set up

question

client has a newly diagnosed lung disease and placed on 2 L of nasal oxygen while hospitalized the client has only been on o2 for appx. 30 minutes when suddenly seems even more short of breath than previously. although he is neither gray or ashy in color the nurse recognizes that the client is experienced in which of the following

answer

oxygen induced hypoventilation

question

which manifestations in a client receiving oxygen therapy at 60 % for more than 24 hours would alert the nurse to possibility of o2 toxicity

answer

increase dyspnea

question

a client receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. what the nurse do first

answer

assess pulse oximetrey

question

the nurse assesses the client receiving oxygen via partial rebreather mask, the nurse will intervene for which assessment finding

answer

oxygen flow rate is at 2 L

question

a client is to be discharged to home on oxygen therapy what information will the nurse teach the client

answer

the d and c cylinder can be carried

question

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

answer

call the physician

question

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

answer

ventilate with resuscitation bag with mask and at the same time call for help

question

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

answer

perform a more thorough assessment

question

the nurse is teaching the client about his fenestrated tracheotomy tube which statement by the client indicates an accurate understanding of the tube

answer

im glad i will still be able to talk with this tube in place

question

the nurse observes the nursing student suctioning the client which intervention on the nursing student has the greatest potential to cause tissue damage

answer

applying suction when the catheter is inserted

question

the nurse assess the client during suctioning, which finding indicates that the procedure should be stopped

answer

the heart decreases from 70 to 40

question

which action is highest priority for the nurse to teach the client with a tracheotomy to decrease the risk for aspirations

answer

thicken all liquids

question

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

answer

respiratory rate of 6

question

which statement by the client indicates that he has an accurate understanding of home self care of his tracheotomy

answer

i need to keep water from entering the airway

question

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

answer

placing the dry dressing over the stoma and secure it in place

question

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

answer

help the client drape attractive scarves so the tracheotomy is hidden

question

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

answer

i clean his mouth water and a toothette

question

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

answer

suction using clean technique

question

the client is experiencing acute rhinitis which intervention is most important for the nurse to include in the clients plan of care

answer

monitor for drug effects such as vertigo hypertension urinary retention and insomnia

question

which is the highest priority teaching need for a client with sinusitis

answer

increase fluid intake

question

the nurse is caring for a client with recurrent bacterial pharyngitis, which is the nurses highest priority intervention

answer

verify that the client understands the importance of completing the entire antibiotic prescription

question

what is essential for the nurse to teach the client who is believed to to have developed pneumonia about using a nebulizer at home

answer

assess whether the clients home cleaning level nebulizer is adequate

question

which should be the priority intervention of the teaching plan to instruct a client about the proper use of an incentive spirometer

answer

instruct the client to exhale and take a breath for 5-10 seconds

question

which statement indicates the nurse understands the spread of severe acute respiratory syndrome SARS

answer

I will use airborne and contact precautions when I am in contact with the client

question

which statement is correct about the care of the client with Avian influenza

answer

the client will be placed on airborne contact isolation and will receive oxygen

question

which statement by the nurse indicates an accurate understanding of TB as a disease process

answer

the client can have a negative skin test if he is immunocompromised

question

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

answer

continuously remove subglottic secretions

question

which is the nurses best response when a client ask how the common cold is transmitted

answer

the cold can be spread by droplets from sneezing and coughing through secretions

question

which client will caution to avoid taking over the counter decongestants for manifestations of a cold or flu

answer

a middle age woman with hypertension

question

the client has a recurrences of a Streptococcal infection, which additional assessment would be performed so the nurse can assess for complications

answer

Urinalysis

question

what is the priority action to teach a client to prevent the spread of colds

answer

washing your hands after blowing your nose and sneezing

question

an older client was prescribed a antihistamine which medical problem may be aggravated by this medication

answer

urinary retention

question

which client's statement alert the nurse the possibility of rhinitis mediacamentosa

answer

my nose doesn't stay open even though i use nasal spray every hour

question

which intervention will the nurse include in discharge teaching after sinus surgery to prevent bleeding from the surgical site

answer

use a stool softener

question

the client has a peristonsillar abscess which is the priority instruction the nurse will provide to this client

answer

take the antibiotic for the entire time it is prescribed not just until you feel better

question

which client statement indicates a need for clarification regarding the cause and treatment of acute laryngitis

answer

i suck on lozenges to keep my mouth and throat from getting so dry

question

an older adult client with heart failure asks when she should get a flu shot, which is the nurses best response

answer

get a flu shot in the early fall so you can make enough antibodies before flu season arrives

question

which assessment finding alerts the nurse to the possibilities of pneumonia in the client with chronic bronchitis

answer

percussion is dull in the left lower lobe

question

which person is at greater risk for developing a community acquired pneumonia

answer

an older adult who smokes and has a substance abuse problem

question

the nurses assesses which client for nosocomial pneumonia

answer

the client receiving mechanical ventilation

question

which is the nurses best response to an older adult client who is hesitant to take the pneumococcal vaccination in the same year

answer

the flu shot may protect you against influenza but won't protect against bacteria that causes pneumonia

question

which is a priority teaching intervention for the client who is using a nicotine patch

answer

smoking while using this patch increases the risk of heart attack

question

the client with TB asks his nurse when he will be considered non infectious. which is the nurses best response

answer

when you have 3 negative sputum cultures 3 in a row

question

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

answer

using standard and airborne precautions until a chest xray shows no evidence of TB

question

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

answer

reexamine the test site in 72 hours

question

which assessment finding alerts the nurse to the possibility of pleura effusion and emphysema

answer

absences of fremitus at on below the site on injury

question

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

answer

No addition precautions inhalation anthrax does not spread by person to person contact

question

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

answer

you need to take it for 60 days it may take 8 weeks for symptoms to appear

question

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

answer

it would decrease the hormone activity

question

how does the tropic hormone differ from other hormones

answer

a tropic hormones stimulate other endocrine glands to secrete hormones

question

which will the nurse assess next in a male client who begins to have fluid secretions from his breast

answer

anterior pituitary hormones

question

the client is receiving 300 mg of morphine daily for severe pain, which is the nurses priority intervention

answer

measuring input and output

question

which affects does the nurse expect daily cortisol therapy to have on client circulating client levels ACTH and aldosterone

answer

decrease acth and decrease aldosterone

question

which is the clinical manifestation for a client who has excessive production of the melanocytes stimulating hormone

answer

darkening of the skin

question

which assessment finding in client taking a drug that stimulate beta 1 receptors requires immediate action of the nurse

answer

pulse rate 50 bpm

question

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

answer

forgetfulness is symptom of addison's disease i will tell your doctor you are concerned

question

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

answer

Transdermal patch

question

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

answer

setting an alarm and take the drug at a scheduled time

question

the client has a hormone deficiency which deficiency is the highest priority

answer

Thyroid stimulating hormone

question

which safety measure will the nurse use who has growth hormone deficiency

answer

using a lift sheet to reposition the client

question

the male client has hyperpituitarism and asks the nurse how long he will have to take testosterone therapy. which is the nurses best response

answer

it is life long

question

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

answer

The client has a normal pituitary response to insulin

question

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

answer

llimiting fluid intake keeps urine from becoming diluted

question

which safety measure is most important for the nurse to initiate for a client who has cushing's disease

answer

using a lift sheet

question

which dietary alterations will the nurse make for the client with cushings disease

answer

low carbohydrate, high calorie and low sodium

question

the client has received vasopressin for diabetes insipidus, which assessment finding indicates a therapeutic response to therapy

answer

urine output is decreased and specific gravity is increased

question

which client statement indicates a need for further clarification regarding medications after a bilateral adrenalectomy

answer

if I have nausea and vomiting I will skip the medication until it resolves

question

the client has chronic hypercortisolism which intervention is highest priority for the nurse

answer

washing hands when entering the room

question

a client present with elevation in T3 and T4 and decrease in TSH levels which is the nurses priority intervention

answer

monitor the apical pulse

question

which dietary modifications will the nurse provide with client with hyperhyroidism

answer

increase calories, proteins and carbs

question

which patient would not be to have radioactive iodine therapy

answer

pregnant women

question

the client with hyperthyroidism is taking lithium carbonate. which findings indicate that the client is having side effects of this therapy

answer

lithium increases thirst and urination

question

12 hrs after a thyroidectomy, client develops stridor on exhalation. which is the nurses priority intervention

answer

calling for emergency assistance

question

which is a priority nursing diagnosis for a client with hypothyroidism

answer

disturbed through process

question

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

answer

you'll have thyroid replacement therapy for life because the gland function will not return

question

which client intervention will the nurse use to prevent injury in a client with hyperparathryoidism

answer

use a lift sheet

question

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

answer

hypocalemia

question

which alteration in vital signs is most indicative of hypothyroidism

answer

apical rate of 50 bpm

question

when fecal urobilinogen concentration levels are decreased as result of biliary cirhosis the stool becomes lighter or clay colored.

answer

clay colored stools

question

the nurse recognizes that fector hepaticus is consistent with which assessment finding

answer

fruit or musty breath odor

question

for the client with cirrhosis which nursing intervention would be most effective in fluid accumulation in the abdominal cavity

answer

providing a low sodium diet

question

which clinical finding does the nurse expect to find observe in a client who has just undergone peritoneal shunt replacement

answer

increase blood pressure

question

the client with obstructive jaundice asks why his skin is so itchy. what is the nurses best response

answer

itching is caused by accumulation of bile salts on the skin

question

nurse caring for a client with cholecystitis. which alerts the nurse the condition chronic rather than acute

answer

the client has clay colored stools and amber urine

question

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

answer

I will have small low fat meals

question

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

answer

documenting the findings in the clients chart

question

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

answer

ambulate the client in the hallway

question

during a physical assessment the nots the presence of turners sign which is the nurses priority action

answer

ensuring the client has a patent large bore IV site

question

the nurse is caring for a client with chronic pancreatitis, which statement by the client indicates additional teaching is needed

answer

i will avoid simple carbohydrates and concentrated sweet

question

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

answer

determine if the client feels like talking about his or her feelings

question

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 do for the client

answer

Adding additional amino acids to the clients tpn solution

question

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

answer

the nurse does not hear any bowel sounds in the clients abdomen

question

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,

answer

decreases it

question

which effect does the nurse expect daily cortisol therapy to have on clients circulatory levels of acth and aldosterone,

answer

decrease aldosterone and acth

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