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Terms in this set (75)Which assessment finding is considered the earliest sign of decreased tissue oxygenation? Unexplained restlessness Which physical assessment maneuver is the nurse performing when instructing the client to breathe in slowly and a little more deeply than normal through the mouth? Auscultation Which physical assessment findings of a client suspected of having a respiratory disorder would be considered normal? Select all that apply. Pink nasal mucosa, midline trachea, non labored breathing of 14/min What finding would be consistent with long-standing hypoxemia in a client who reports shortness of breath? Clubbing A client is admitted with a sudden onset of dyspnea and chest pain. What are the interventions in the order in which the nurse will perform them to provide comfort to the client? 1. Notifying the Rapid Response Team Which would the nurse consider to be a potential respiratory system-related complication of surgery? Atelectasis An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation? Teach coughing and deep-breathing exercises. The nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation? Stop administering the medication A child who reports shortness of breath, wheezing, and coughing is found to have pulmonary edema and is prescribed furosemide. Which nursing interventions would be beneficial to the client? Select all that apply. Checking the child's weight every day Continuous high-pitched squeaking or musical sounds that result from rapid vibration of bronchial walls. They are associated with bronchospasms or airway obstruction Wheezing Creaking or grating sounds caused by roughened, inflamed pleural surfaces rubbing together. They are associated with pleurisy, pneumonia, or a pulmonary infarct. Pleural friction rubs Normal, low-pitched rustling sounds heard over peripheral lung fields Vesicular breath sounds Normal, harsh, hollow, tubular, blowing sounds heard over the trachea and larynx. Bronchial breath sounds What condition would a nurse suspect in a client with abnormal respirations with alternating periods of apnea and rapid breathing? Cheyne-Stokes respirations The normal RBC count for a healthy male 4.7-6.1 million A client is transferred to an acute care nursing unit after surgery. Which action of the nurse is most important and should be performed first? Assess the patency of airway. The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? A low hemoglobin level causes reduced oxygen-carrying capacity. A client receives a prescription for morphine via patient-controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first? Respirations While reviewing the medical reports in an acute care setting, the nurse finds that the client is at risk for kidney damage and requests the healthcare provider to increase the intravenous fluid rate as a priority nursing intervention. Which finding supports the nurse's conclusion? Urine output is 25mL/hr What is the priority nursing action for a client with delirium? creating a calm safe environment What should be the priority action of the nurse who is caring for a client with a leg in traction? Assessing skin integrity What is considered to be the highest priority for an assault victim who presents to the emergency department? Ensuring the client's emotional and physical safety The nurse is caring for a client with a platelet count of 50,000 cells per microliter. Which recommendation is inappropriate for the client? Shaving with a straight blade The nurse is caring for clients in the pulmonary unit and suspects that one has tuberculosis. What is the priority nursing intervention in this situation? Move patient into airborne isolation room The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority? Respiratory rate and sedation. Level 3 sedation needs immediate intervention The client is receiving high-flow intravenous (IV) fluid replacement therapy. Which nursing assessment findings are consistent with fluid volume overload? Bounding pulse, presence of dependent edema, and neck vein distention in the upright position The nurse is caring for a client who survived a severe burn injury. Which action should the nurse perform immediately based on priority? Assessing airway patency What are the priority nursing interventions for a client with neutropenia in an emergency department? Obtain blood cultures immediately, Administer antibiotics STAT as prescribed While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation? Stop the blood transfusion immediately. Which first line medication would the nurse state is used to treat anaphylactic reactions? Epinephrin Which nursing intervention for opening the airway should be performed in an unconscious client with a spinal injury? Performing a jaw thrust maneuver. In what ways can a nurse prevent medication errors? Avoid using abbreviations and acronyms Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do -Assess the client's condition every hour. A restraint impedes the movement of a client; therefore a client's condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours. Restraints should be removed and activity and skin care provided at least every 2 hours to prevent contractures and skin breakdown. Output from tubes may be monitored hourly, but generally does not need to be documented as frequently as every 2 hours. Generally output from tubes is emptied, measured, and documented at the end of each shift. A client who is in critical condition or in the immediate postoperative period may have urinary output measured hourly because this reflects cardiovascular status A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report? A listing of facts related to the incident as witnessed by the nurse A primary healthcare provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this prescription? Recognizing that PRN prescriptions for restraints are unacceptable A client with multiple injuries from a motor vehicle accident now is permitted out of bed to a chair but is not permitted to bear weight on the lower extremities. When using a mechanical lift to transfer the client, it is essential that the nurse do what? Fold the client's arms across the chest A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and doing what next Bending and then straightening their knees An elderly adult with Parkinson's disease falls while going to the bathroom and gets injured. The nurse taking care of the client informs the primary healthcare provider. What step should the nurse take to alert the risk management system? The nurse should document the incident in the occurrence report tool The nurse finds that the client's fever spikes and falls without a return to a normal level. Which pattern of fever is this a characteristic of? Remittent Which are extrinsic factors responsible for falls in older adults? Environmental hazards An older adult experiencing delirium suffers from a leg fracture caused by a fall. Which interventions should the nurse follow to prevent future falls? Minimizing medications Which intrinsic factors may contribute to falls in older adults? Deconditioning The primary healthcare provider prescribes thioridazine and assigns the nurse to assess the client for orthostatic hypotension. Which interventions would the nurse perform? -Measuring the blood pressure before dosing What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension? Sit on the edge of the bed for 5 minutes before standing The nurse assesses a client for orthostatic hypotension. The results are: No prescription change
The nurse is teaching a group of student nurses about caring for a hospitalized immunosuppressed client. Which statement(s) made by the student nurse indicates the need for further teaching? -"I should inspect the client's mouth at least every 4 hours."
Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? Removing the catheter within 24 hours The registered nurse is evaluating the statements of a new orienting nurse about wound dressing. Which statement made by the new orienting nurse indicates the need for further teaching? I should take the cotton swap placed on the table The registered nurse finds that a client cared for by a student nurse has developed an infection. Which action of the student nurse does the registered nurse suspect to be the cause of infection? Use of a wet dressing Which condition is an example of a bacterial infection? Impetigo The registered nurse is teaching a student nurse about the interventions to be followed by a client to prevent the spread of infection. Which statement made by the student nurse indicates the need for further learning? I will advise the client to squeeze pustules Which is an example of indirect contact transmission of microorganisms? Dirty
hands. A new nurse has been assigned to a school-aged child who is in contact isolation for methicillin-resistant Staphylococcus aureus (MRSA). The primary nurse observes the new nurse during morning care. Which behavior should the primary nurse address to improve isolation technique? -While changing the bed the nurse wears gloves but no gown Organisms spread by contact could be present on linen and furniture. Because the nurse will likely come in contact with the bed or the sheets, a gown should be worn. A mask is not required for contact isolation. Clean gloves are appropriate; sterile gloves are not necessary. No other protective gear is needed, because the nurse's hands are the only part of the body that might touch the child. Equipment brought into the room must be disinfected before it is removed from the room. A hospitalized client is on contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). Which statement by an unlicensed assistive personnel (UAP) (Canada: continuing care assistant, CCA) indicates a need for further teaching? "I will remove the gown, then the gloves, before washing my hands. Which diseases can be transmitted from client to client by droplet infection? Pertussis For which illness should airborne precautions be implemented? Chickenpox A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions? Sputum is free of acid-fast bacteria A client's sputum smears for acid-fast bacilli (AFB) are positive, and transmission-based airborne precautions are prescribed. What should the nurse teach visitors to do? Wear a particulate respirator mask. A registered nurse is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? Bringing equipment to the client's room When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? Airborne A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The healthcare provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? Surgical asepsis A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). What precautions should the nurse take when caring for this client? Use standard precautions While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures and that the episodes are longer than 24 hours. Which fever pattern does the nurse anticipate? Relapsing The registered nurse (RN) is delegating tasks to several health care team members caring for a client with a bacterial infection and high fever. Which statements by the registered nurse would be most appropriate for the licensed practical nurse (LPN)? "You should administer an antipyretic after the meal." The registered nurse is assisting a client who is hospitalized with high fever. Which task delegated to the unlicensed assistive personnel (UAP) would be appropriate? Performing all hygiene tasks A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past 2 days. What is the first thing the nurse should do when caring for this client? Take temperature A 13-month-old toddler has a respiratory tract infection with a low-grade fever. When teaching the parents, which intervention should the nurse emphasize? Giving small amounts of clear liquids frequently to prevent dehydration A client with Crohn disease is admitted to the hospital with abdominal pain, fever, poor skin turgor, and diarrhea, with 10 stools in the past 24 hours. Which signs are evidence that the client most likely is dehydrated? Sunken eyes A client is admitted to the emergency department with dyspnea, a productive cough, and fever. The healthcare provider suspects pneumonia and writes prescriptions. Place the nursing actions in the order they should be performed. 1. Elevate the head of the bed. The nurse enters the client's room to do the beginning of shift assessment and notices the client has no pulse. What should be the nurse's first intervention? Initiating cardiopulmonary resuscitation A nursing student is recording the radial pulse rate in a client with dysrhythmias and documented a radial pulse of 80 beats per minute. The registered nurse reassesses the client and notices a pulse deficit of 15. What is the client's apical pulse? 95 A nursing student under the supervision of a registered nurse is performing a pulse assessment. While preparing to assess the client, the registered nurse asks the nursing student to check the apical pulse after assessing the radial pulse. What could be the reason behind for this change? The client may have a dysrhythmia A client who has been admitted to the hospital with chest pain complains of shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. Which site is the most appropriate place to check the client's pulse rate? Femoral A client with chest pain, shortness of breath, weakness, and vomiting may be experiencing cardiac arrest. In a client with cardiac arrest, the most appropriate place to check the pulse rate is the femoral site, because other pulses may not be palpable at this time. Which clients should be considered for assessing the carotid pulse? Client with cardiac arrest A client is hospitalized with an overdose of benzodiazepines and presents with a respiratory rate less than 10 breaths per minute. Which nursing intervention should be provided as the first priority? Give oxygen Sets with similar termsadaptive review test 192 terms Rebekah_Jade Comp 5158 terms kendallkissir Nursing Level 4, Test 4: HIV, Organ Transplant, Li…80 terms Kelsea_Noble comprehensive NCLEX93 terms lro2012 Sets found in the same folderEvolve Fundamentals - Basics101 terms tiggie86 med surg EAQs97 terms tu_quynh Evolve: Respiratory System23 terms Zaynawin_EscobarPLUS Med-Surge (Upper Respiratory EAQ)13 terms haven9105 Other Quizlet setsMedgas123 terms ashash00284 Apush chapter 232 terms libbyrcorea Chapter 1: Managing Human Resources90 terms KayleeLeeAnn28PLUS Neuro- L7- Thalamus & basal ganglila75 terms raquel_santos23 Related questionsQUESTION The charge nurse uses a medical word that the Nurse Assistant does not understand. What should you do? 15 answers QUESTION After the significant others leave the room, obtain a shroud or postmortem pack, and a morgue stretcher. 2 answers QUESTION An adult has difficulty imitating a conversation, and in working with others always agrees with them because "my opinion is not important." Which of Maslow's basic needs is not being met by this person? 9 answers QUESTION The nurse is caring for a client with an acute myocardial infarction. The nurse understands that this condition results in cardiogenic shock by which mechanism? 3 answers Which step should the nurse take to alert the risk management system after notifying the primary health care provider of a client's fall?The nurse taking care of the client informs the primary healthcare provider. What step should the nurse take to alert the risk management system? The nurse should document the incident in the occurrence report tool.
Which nursing intervention for opening the airway should be performed in an unconscious client with a spinal injury?If you think the person may have a spinal injury, place your hands on either side of their head and use your fingertips to gently lift the angle of the jaw forward and upwards, without moving the head, to open the airway. Take care not to move the person's neck.
Which physical assessment maneuver is the nurse performing when instructing the client to breathe slowly?What is the Valsalva maneuver? The Valsalva maneuver is a particular way of breathing that increases pressure in the chest. It causes various effects in the body, including changes in the heart rate and blood pressure. People may perform the maneuver regularly without knowing it.
Which is an appropriate method of assessing a patient's respirations?Which is an appropriate method of assessing a patient's respirations? Place the patient's arm or the examiner's hand gently over the patient's upper abdomen. The nurse is assessing the respiratory rate of a 3-year-old patient and notices an irregular pattern and rate.
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Which would the nurse consider to be a potential respiratory system related complications of surgery?
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