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A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which action by this team member is most appropriate? A. B. C. D. Apply a heating pad to the involved site. Elevate the client’s legs 90 degrees. Instruct the client about the need for bed rest. Provide active range-of-motion exercises to both legs at least twice every shift. 5.
Blood gases are monitored using a pulse oximeter.
When suctioning mucus from a client’s lungs, which nursing action would be least appropriate? A. Lubricate the catheter tip with sterile saline before insertion. B. Use sterile technique with a two-gloved approach
A client receiving heparin sodium asks the nurse how the drug works. Which of the following points would the nurse include in the explanation to the client? A. B. It dissolves existing thrombi. It prevents conversion of factors that are needed in the formation of clots. C. It inactivates thrombin that forms and dissolves existing thrombi. D. It interferes with vitamin K absorption. 6.
Suction until the client indicates to stop or no longer than 20 second
Hyperoxygenate the client before and after suctioning
Dr. Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive Tuberculin skin test. When informing the client of this decision, the nurse knows that the purpose of this choice of treatment is to A. B. Cause less irritation to the gastrointestinal tract Destroy resistant organisms and promote proper blood levels of the drugs C. D. Gain a more rapid systemic effect Delay resistance and increase the tuberculostatic effect
The nurse is conducting an education session for a group of smokers in a “stop smoking” class. Which finding would the nurse state as a common symptom of lung cancer? : A. B. C. D. Dyspnea on exertion Foamy, blood-tinged sputum Wheezing sound on inspiration Cough or change in a chronic cough 7.
Mario undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and onebottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Mario is placed in
Which is the most relevant knowledge about oxygen administration to a client with COPD? A. Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. B. Hypoxia stimulates the central chemoreceptors in the medulla that makes the client breath. C. Oxygen is administered best using a nonrebreathing mask
Fowler’s position on either his right side or on his back to A. B. C. D. Reduce incisional pain. Facilitate ventilation of the left lung. Equalize pressure in the pleural space. Increase venous return
C. Pupil reaction Hand grips Blood pressure Blood glucose 11. Take heart rate and blood pressure. Decreased tissue perfusion. Which is the most appropriate nursing diagnosis for this patient? A. The nurse is preparing her plan of care for her patient diagnosed with pneumonia. D.” 10. I shouldn’t skip doses. B.” D. What is the nurse’s best initial action? A. A client is scheduled for a bronchoscopy.8. Which assessment is essential for the nurse to make first? A. who is suspected of having Pheochromocytoma. large thighs and upper arms pendulous abdomen and large hips abdominal striae and ankle enlargement posterior neck fat pad and thin extremities 9. who happens to be a diabetic. the skin color is pink. C. 13. The nurse is attending a bridal shower for a friend when another guest. B. 14. Slowly breath out through the mouth with pursed lips after inhaling the drug. C. Lower the oxygen rate. Which statement by the client indicates understanding of the possible side effects of Prednisone therapy? A. and the respirations are 9 per minute and shallow. Impaired gas exchange. C.” B. D.” C. The following are relevant instructions to the client regarding the use of an oral inhaler EXCEPT A. Fluid volume deficit 15. A client. Call the physician. Coughing and deep-breathing exercises will be done q2h. Hold his breath for about 10 seconds before exhaling D. “My incision will heal much faster because of this drug. “I should limit my potassium intake because hyperkalemia is a side-effect of this drug. Inhale slowly through the mouth as the canister is pressed down C. starts to . D. D. B. Warm saline gargles will be done q 2h. the nurse’s highest priority of information would be A. C. Position the client in a Fowler’s position. B. complains of sweating. A client with COPD is being prepared for discharge. B. Risk for infection 12. D. “This medicine will protect me from getting any colds or infection. palpitation and headache. When teaching the client what to expect afterward. “I must take this medicine exactly as my doctor ordered it. A nurse at the weight loss clinic assesses a client who has a large abdomen and a rounded face. Which additional assessment finding would lead the nurse to suspect that the client has Cushing’s syndrome rather than obesity? A. B. Food and fluids will be withheld for at least 2 hours. Only ice chips and cold liquids will be allowed initially. The nurse enters the room of a client with chronic obstructive pulmonary disease. Breath in and out as fully as possible before placing the mouthpiece inside the mouth. The client’s nasal cannula oxygen is running at a rate of 6 L per minute.
Call the guest’s personal physician Offer the guest a cup of coffee Give the guest a glass of orange juice . C. D. The next best action for the nurse to take is to: A. Encourage the guest to eat some baked macaroni B.tremble and complains of dizziness.
Giving the clientoxygen in low concentrations will maintain the client’s hypoxic drive. . The hypoxic state of the client then becomes the stimulus for breathing. The irritation causes the cough which initially maybe dry. persistent and unproductive. 3. Suctioning sucks not only the secretions but also the gases found in the airways. Heparin is an anticoagulant. Answer: (C) Suction until the client indicates to stop or no longer than 20 second One hazard encountered when suctioning a client is the development of hypoxia. obstruction of the airways occurs and the cough may become productive due to infection. 4. As the tumor enlarges.1. Answer: (B) It prevents conversion of factors that are needed in the formation of clots. This can be prevented by suctioning the client for an average time of 5-10 seconds and not more than 15 seconds and hyperoxygenating the client before and after suctioning. In a client with thrombophlebitis. It prevents the conversion of prothrombin to thrombin. 2. Answer: (C) Instruct the client about the need for bed rest. It does not dissolve a clot. Answer: (D) Cough or change in a chronic cough Cigarette smoke is a carcinogen that irritates and damages the respiratory epithelium. bedrest will prevent the dislodgment of the clot in the extremity which can lead to pulmonary embolism. 5. Answer: (A) Oxygen at 1-2L/min is given to maintain the hypoxic stimulus for breathing. COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing.
which is an infection. Answer: (C) Lower the oxygen rate. Answer: (B) Facilitate ventilation of the left lung. The increasing prevalence of drug resistance points to the need to begin the treatment with drugs in combination. this makes him prone to fluid volume excess. the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Pneumonia. 8. Fat may also accumulate on the face.6. there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side. All these are noted in a client with Cushing’s syndrome. 12. Giving O2 inhalation at a rate that is more than 2-3L/min can make the client lose his hypoxic drive which can be assessed as decreasing RR. 7. The gag reflex usually returns after two hours. causes lobar consolidation thus impairing gas exchange between the alveoli and the blood. 13.” . 9. Answer: (A) Food and fluids will be withheld for at least 2 hours. If the client breathes out through the mouth with pursed lips. The hypoxic drive is his chief stimulus for breathing. Using drugs in combination can delay the drug resistance. Answer: (D) posterior neck fat pad and thin extremities “ Buffalo hump” is the accumulation of fat pads over the upper back and neck. Since only a partial pneumonectomy is done. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. There is truncal obesity but the extremities are thin. Answer: (D) Slowly breath out through the mouth with pursed lips after inhaling the drug. 11. The client with COPD is suffering from chronic CO2 retention. Answer: (D) Delay resistance and increase the tuberculostatic effect Pulmonary TB is treated primarily with chemotherapeutic agents for 6-12 mons. Because the patient would require adequate hydration. this can easily force the just inhaled drug out of the respiratory tract that will lessen its effectiveness. 10. I shouldn’t skip doses. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. Prior to bronchoscopy. Answer: (C) Impaired gas exchange. Answer: (B) “I must take this medicine exactly as my doctor ordered it.
the nurse should watch out for signs of hypoglycemia manifested by dizziness. pallor diaphoresis and tachycardia. weakness. increase tendency to infection and poor wound healing.The possible side effects of steroid administration are hypokalemia. hard candy. glucagons or dextrose per IV. . tremors. Answer: (C) Blood pressure Pheochromocytoma is a tumor of the adrenal medulla that causes an increase secretion of catecholamines that can elevate the blood pressure. honey or. Answer: (D) Give the guest a glass of orange juice In diabetic patients. Clients on the drug must follow strictly the doctor’s order since skipping the drug can lower the drug level in the blood that can trigger acute adrenal insufficiency or Addisonian Crisis 14. When this occurs in a conscious client. if unconscious. 15. he should be given immediately carbohydrates in the form of fruit juice.