-cocci Berry shaped bacteria.
-graph Instrument to record.
-oid Resembling
-ptosis Prolapse
-scope Instrument to visually examine.
-stomy Surgical creation of a permanentopening to the outside ofthe body.
-therapy Treatment.
A 25-year-old client was admitted yesterday after a motorvehiclecollision. Neurodiagnostic studies showed a basal skullfracture inthe middle fossa. Assessment on admission revealed bothhalo andBattle signs. Which new symptom indicates that the clientis likelyto be experiencing a common life-threateningcomplicationassociated with basal skull fracture?
A. Bilateral jugular vein distention.B. Oral temperature of 102degrees F.C. Intermittent focal motor seizures.D. Intractable painin the cervical region.
B. Increased temp indicatesmeningitis. (C & D) thesesymptomsmay be exhibited but are not lifethreatening. (A) JVD isnot a typicalcomplication of basal skull fractures.
39. Select all that apply. Which of the following areclinicalmanifestations of tension pneumothorax? A. Midline trachea B.Severe hypertension C. Progressive cyanosis D. A loud bruit onaffected side E. Asymmetrical chest wall movement F. Subcutaneousemphysema in the neck
C,E, F The indicators of tensionpneumothorax areasymmetricalchest wall movement, severehypotension,subcutaneousemphysema in the neck and upperchest, and progressivecyanosis.
41. Select all that apply. During initial assessment, anurseshould record which of the followingmanifestations of respiratorydistress? A. Tachypnea B. Nasal flaring C. Thready pulse D. Pantingor grunting E. Use of intercostal muscles F. Aninspiratory-to-expiratory ratio of 1:2
AD Manifestations of respiratorydistress include tachypnea,gruntingand panting on respiration, centralcyanosis, use ofaccessory muscles,and flaring nares.
42. Select all that apply. Which of the followingnursing actionscan help clear tracheobronchialsecretions in a patient with cysticfibrosis? A. Postural drainage B. Suppressing the cough C. Ensuringadequate hydration D. Administering mucolytic aerosols E.Encouraging the patient to lie flat F. Administering water-solublevitamins
ACD Postural drainage, adequatehydration, and administrationofmucolytic aerosols all encouragecoughing and the clearing ofsecretions.A patient with cystic fibrosis will be morecomfortablesitting upright.
A 43-year-old homeless, malnourished female client with ahistoryof alcoholism is transferred to the ICU. She is placed ontelemetry,and the rhythm strip shown is obtained. The nursepalpates a heartrate of 160 beats/min, and the client's bloodpressure is 90/54.Based on these finding, which IV medicationshould the nurseadminister?
A. Amiodarone (Cordarone)B. Magnesium sulfateC. Lidocaine(Xylocaine)D. Procainamide (Pronestyl)
B. Because the client has chronic alcoholism, she is likelytohave hypomagnesium. (B) is the recommended drugfor torsades depointes (AHA, 2005), which is a form ofpolymorphic ventriculartachycardia (VT), usuallyassociated with a prolonged QT intervalthat occurs withhypomagnesemia. (A and D) increase the QTinterval,which can cause the torsades to worsen. (C) istheantiarrhythmic of choice in most cases ofdrug-inducedmonomorphic VT, not torsades.
43. Select all that apply. Which of the following isincluded ina comprehensive respiratory assessment?A. Pulse oximetry B. Chestauscultation C. Apical radial pulse D. Nail-bed assessment E.Evaluation of respiratory effort F. Rate and character ofrespirations
ABDEF The total assessment of therespiratory system includespulseoximetry; auscultation; skin and nail-bedassessment for thedetection of cyanosis;and rate, character, and degree of effortofrespirations. The apical radial pulse isa cardiac assessment.
A 45-year-old man with asthma is brought to theemergencydepartment by automobile. He is short ofbreath and appearsfrightened. During the initial nursingassessment, which of thefollowing clinical manifestationsmight be present as an earlysymptom during anexacerbation of asthma? A. Anxiety B. Cyanosis C.Hypercapnia D. Bradycardia
A. Anxiety An early symptom during anasthma attack is anxietybecause he isacutely aware of the inability to getsufficient air tobreathe. He will behypoxic early on with decreased PaCO2andincreased pH as he ishyperventilating.
A 55-year-old male client is admitted to the coronarycare unithaving suffered an acute myocardialinfarction (MI). Within 24 hoursof the occurrence,the nurse can expect to find which systemicsign?
A. Elevated serum amylase levelB. Elevated CM-MB levelC.Prolonged prothrombin time (PT)D. Elevated serum BUN andcreatinine
B. Tissue damage in the myocardium causes the release ofcardiacenzymes into the blood system. An elevated CM-MB is a recognizedindicator of an MI. It peaks 12 - 24hours and returns to normalwithin 48 - 78 hours. (A)would indicate pancreatitis or a gastricdisorder. (D)Although an elevated BUN might be related to anacuteMI it is usually associated with dehydration, highproteinintake or gastrointestinal bleeding and creatinelevelsindicate renal damage. (C) Indicates effectiveanticoagulationtherapy.
A 58-year-old client, who has no health problems, asks the nurseabout takingthe pneumococcal vaccine (Pneumovax). Which statementgive by the nursewould offer the client accurate information aboutthis vaccine?
A. "The vaccine is given annually before the flue season tothose over 50 yearsof age."B. "The immunization is administeredonce to older adults or persons with ahistory of chronicillness."C. "The vaccine is for all ages and is given primarily tothose person travelingoverseas to infected areas."D. "The vaccinewill prevent the occurrence of pneumococcal pneumonia for upto 5years."
B. It is usually recommended that personsover 65 years of ageand those with a historyof chronic illness should receive thevaccineonce in a lifetime. (A) the influenza vaccine isgivenannually. (C) travel is not the mainrationale for the vaccine. (D)The vaccine isusually given once in a lifetime.
A 71-year-old patient is admitted with acute respiratorydistressrelated to cor pulmonale. Which of the followingnursinginterventions is most appropriate during admission of thispatient?A. Delay any physical assessment of the patient and reviewwiththe family the patient's history of respiratory problems. B.Performa comprehensive health history with the patient to reviewpriorrespiratory problems. C. Perform a physical assessment of therespiratory system and askspecific questions related to thisepisode of respiratory distress. D. Complete a full physicalexamination to determine the effect ofthe respiratory distress onother body functions.
C. Perform a physical assessment of the respiratorysystem andask specific questions related to thisepisode of respiratorydistress.Because the patient ishaving respiratory difficulty, thenurse should askspecific questions about this episode and performaphysical assessment of this system. Further historytaking andphysical examination of other bodysystems can proceed once thepatient's acuterespiratory distress is being managed.
A 75-year-old obese patient who is snoringloudly and havingperiods of apnea severaltimes each night is most likelyexperiencing A. narcolepsy. B. sleep apnea. C. sleep deprivation.D. paroxysmal nocturnal dyspnea.
B. sleep apnea. Sleep apnea is most common in obesepatients.Typical symptoms include snoring andperiods of apnea. Narcolepsy iswhen a patient fallsasleep unexpectedly. Sleep deprivation couldresultfrom sleep apnea. Paroxysmal nocturnal dyspneaoccurs when apatient has shortness of breath duringthe night.
absorption atelectasisalveolar collapse that occurs whenhighconcentrations of oxygen are given andoxygen replaces nitrogenin the alveoli; ifairway obstruction occurs, the oxygen isabsorbedinto the bloodstream and thealveoli collapse.
Absorption of vitamin B12 may be decreased in olderadultsbecause of decreased A. intestinal motility. B. production of bileby the liver. C. production of intrinsic factor by the stomach. D.synthesis of cobalamin (vitamin B12) by intestinalbacteria.
C. production of intrinsic factor by the stomach. Older personsare at risk fordeficiency of cobalamin (pernicious anemia) becauseof a naturally occurringreduction of the intrinsic factor by thestomach mucosa. Absorption ofcobalamin relies on intrinsic factor.Both must be present for absorption.Megaloblastic anemia is relatedto folate dysfunction. Intestinal motility(peristalsis) is themotion that moves food down the GI tract. The rhythmiccontractionsof muscles cause wave-like motions. Lack of peristalsis iscalled"paralytic ileus." Bile is produced in the liver, is storedand concentrated in thegallbladder, and is released into theduodenum when fat is eaten. Bileemulsifies fats and prepares themfor enzyme digestion in order for thenutrient to be absorbed intolymph and eventually into blood vessels to theliver. Vitamin K (theblood-clotting vitamin) is synthesized by intestinalbacteria.
ACE inhibitorcough os a common side effect
hypertensiondo not stop abruptly (rebound
hypertension may occur)
Acromegaly Enlargement of extremities afterpuberty due topituitary glandproblem.
acute bronchitis an inflammation of the lowerrespiratory tractthat is usually due toinfection.
Adipose Pertaining to fat.
adventitious soundsextra breath sounds that are notnormallyheard, such as crackles,
rhonchi, wheezes, and pleural frictionrubs.
After a posterior nasal pack is inserted by a physician,thepatient is very anxious and states, "I don't feel likeI'mbreathing right." The immediate intervention the nurseshouldinitiate is to A. monitor ABGs. B. reassure the patient that thisis normal discomfort. C. cut the pack strings and pull the packingout with ahemostat. D. direct a flashlight into the patient's mouthand inspectthe oral cavity.
D. direct a flashlight into the patient's mouth andinspect theoral cavity. The nurse should inspect theoral cavity for thepresence of blood, soft palatenecrosis, and proper placement of theposterior plug.If the posterior plug is visible, the physicianshouldbe notified for readjustment of the packing.Reassurance,cutting the strings, and ABGs are nottop priority interventions.The nurse needs furtherdata before intervening.
After admitting a patient to the medical unit with adiagnosis ofpneumonia, the nurse will verify thatwhich of the followingphysician orders have beencompleted before administering a dose ofcefotetan(Cefotan) to the patient? A. Serum laboratory studiesordered for AM B. Pulmonary function evaluation C. Orthostaticblood pressures D. Sputum culture and sensitivity
D. Sputum culture and sensitivityThe nurse should ensure thatthesputum for culture and sensitivity was sent to the laboratorybeforeadministering the cefotetan. It is important that theorganisms arecorrectly identified (by the culture) before theirnumbers are affectedby the antibiotic; the test will also determinewhether the properantibiotic has been ordered (sensitivitytesting). Althoughantibiotic administration should not be undulydelayed whilewaiting for the patient to expectorate sputum, all ofthe otheroptions will not be affected by the administration ofantibiotics.
Aldosteronismlab =decreased serum level of
potassiumhypokalemiahypertension
allergic rhinitis the reaction of the nasal mucosa to aspecificallergen.
alpha 1-antitrypsina serum protein produced by the livernormallyfound in the lungs thatinhibits proteolytic enzymes of whitecellsfrom lysing lung tissue; geneticdeficiency of this protein cancauseemphysema.
Amniocentesis Surgical puncture to remove fluidfrom the sacaround the embryo.
angina pectoris when walking=1.assist to seatedposition; 2.sublingual nitroglycerin;3.oxygen 4. wheelchair to room
Angioplasty Surgical repair of blood vessel.
Anticoagulant therapy is used in thetreatment of thromboembolicdiseasebecause anticoagulants can A. dissolve the thrombi. B.decrease blood viscosity. C. prevent absorption of vitamin K. D.inhibit the synthesis of clotting factors.
D. inhibit the synthesis of clotting factors.Anticoagulanttherapy is based on the premise thatthe initiation or extension ofthrombi can beprevented by inhibiting the synthesis ofclottingfactors or by accelerating their inactivation.Theanticoagulants heparin and warfarin do not inducethrombolysisbut effectively prevent clot extension.
apnea an absence of spontaneousrespirations.
The arterial blood gas (ABG) readings that indicatecompensatedrespiratory acidosis are a PaCO2 of A. 30 mm Hg and bicarbonatelevel of 24 mEq/L. B. 30 mm Hg and bicarbonate level of 30 mEq/L.C. 50 mm Hg and bicarbonate level of 20 mEq/L.D. 50 mm Hg andbicarbonate level of 30 mEq/L.
D. 50 mm Hg and bicarbonate levelof 30 mEq/L. If compensationispresent, carbon dioxide andbicarbonate are abnormal (or nearlyso)in opposite directions (e.g., one isacidotic and the otheralkalotic).
Arteriole Small artery.
asthma
a chronic inflammatory lung disease thatresults in airflowobstruction;characterized by recurring episodes ofparoxysmaldyspnea, wheezing onexpiration and/or inspiration causedbyconstriction of the bronchi, coughing,and viscous mucoidbronchial secretions.
Before beginning a transfusion of RBCs, which of the followingactions by the nurse would be ofhighest priority to avoid an errorduring this procedure? A. Check the identifying information on theunit of blood against the patient's ID bracelet. B. Select newprimary IV tubing primed with lactated Ringer's solution to use forthetransfusion. C. Add the blood transfusion as a secondary line tothe existing IV and used the IV controller tomaintain correct flow.D. Remain with the patient for 60 minutes after beginning thetransfusionto watch for signs of a transfusion reaction. Thepatient's identifying information (name, date ofbirth, medicalrecord number) on the identification bracelet should exactly matchtheinformation on the blood bank tag that has been placed on theunit of blood. If any informationdoes not match, the transfusionsshould not be hung because of possible error and risk tothepatient.
A. The patient's identifying information (name,date of birth,medical record number) on theidentification bracelet should exactlymatch theinformation on the blood bank tag that has beenplaced onthe unit of blood. If any informationdoes not match, thetransfusions should not behung because of possible error and riskto thepatient.
Before discharge, the nurse discusses activity levels witha61-year-old patient with COPD and pneumonia. Which ofthe followingexercise goals is most appropriate once thepatient is fullyrecovered from this episode of illness? A. Slightly increaseactivity over the current level. B. Walk for 20 minutes a day,keeping the pulse rate lessthan 130 beats per minute. C. Limitexercise to activitiesof daily living to conserve energy. D. Swimfor 10 min/day, gradually increasing to 30min/day.
B. Walk for 20 minutes a day, keeping the pulse rateless than130 beats per minute. The patient willbenefit from mild aerobicexercise that does notstress the cardiorespiratory system. Thepatientshould be encouraged to walk for 20 min/day,keeping thepulse rate less than 75% to 80% ofmaximum heart rate (220 minuspatient's age).
Before starting a transfusion of packed red bloodcells for ananemic patient, the nurse would arrangefor a peer to monitor his orher other assignedpatients for how many minutes when thenursebegins the transfusion? A. 60 B. 5 C. 30 D. 15
D. 15 As part of standard procedure, thenurse remains with thepatient for thefirst 15 minutes after hanging a bloodtransfusion.Patients who are likely tohave a transfusion reaction willmoreoften exhibit signs within the first 15minutes that the bloodis infusing.
Bell palsy (7th crainal nerve) unilateral facial weaknessandparalysis
The blood bank notifies the nurse that the two units ofbloodordered for an anemic patient are ready for pick up. Thenurseshould take which of the following actions to prevent anadverseeffect during this procedure? A. Immediately pick up bothunits of blood from the blood bank. B. Regulate the flow rate sothat each unit takes at least 4 hours totransfuse. C. Set up theY-tubing of the blood set with dextrose in water as theflushsolution. D. Infuse the blood slowly for the first 15 minutes ofthetransfusion.
D. Infuse the blood slowly for the first 15 minutes ofthetransfusion. Because a transfusion reaction ismore likely to occurat the beginning of a transfusion,the nurse should initially infusethe blood at a rate nofaster than 2 ml/min and remain with thepatient forthe first 15 minutes after hanging a unit of blood.
blunt trama to back of head LOC assessment most important
cancerreduce fats
increase fruits, vegetables and fiberie bran flakes, skim milk,orange
slices
Catabolism The process by which food is burnedto realeaseenergy.
Cell Membrane Allows materials to pass into and outof thecell.
A central venous catheter has been inserted via a jugular veinand aradiography has confirmed placement of the catheter.Aprescription has been received for stat medication but IVfluidshave not yet been started. What action should the nurse takepriorto administering the prescribed medication?
A. Assess for signs of jugular vein distention.B. Obtain theneeded intravenous solution.C. Administer a bolus of normal salinesolution.D. Flush the line with heparinized saline.
C. A medication can be administered central linewithout IVfluids, flush with normal saline to removeheparin that maycounteract with the medication. (B)is used following the medicationand a second salinebolus. (A) will not impact the the medadministrationand is not a priority. (B) Administration of thestatmedication is more of a priority than (B).
centrilobular emphysematype of emphysema often associatedwithchronic bronchitis in which respiratorybronchioles enlarge, thewalls are destroyed,and the bronchioles becomeconfluent;characterized by enlargement of air spaces inthe proximalpart of the acinus, primarily atthe level of the respiratorybronchioles.
chemoreceptora sensory nerve cell that responds to
a change in the chemical composition(PaCO2 and pH) of the fluidaround
it.
chest percussion rhythmic percussion of a patient'schest withcupped hands to loosenretained respiratory secretions.
chest physiotherapya series of maneuvers includingpercussion,vibration, and posturaldrainage designed to promoteclearance ofexcessive respiratorysecretions.
chest tube decreased drainage =assess for kinksor dependantloops -do not clamp off
Chronic Continuing over a long period oftime.
chronic bronchitis
obstructive pulmonary diseasecharacterized by excessiveproduction ofmucus and chronic inflammatorychanges in the bronchi,resulting in acough with expectoration for at least 3months of theyear for more than 2consecutive years.
The chronic inflammation of the bronchicharacteristic of chronicobstructive pulmonarydisease (COPD) results in A. collapse of smallbronchioles on expiration. B. permanent, abnormal dilation of thebronchi. C. hyperplasia of mucus-secreting cells andbronchialedema. D. destruction of the elastic and muscularstructuresof the bronchial wall.
C. hyperplasia of mucus-secreting cells and bronchialedema.Chronic bronchitis is characterized by chronicinflammation of thebronchial lining, with edema andincreased mucus production.Collapse of smallbronchioles on expiration is common inemphysema,and abnormal dilation of the bronchi becauseofdestruction of the elastic and muscular structuresischaracteristic of bronchiectasis.
chronic pancreatitispulmonary disease state characterized bythepresence of airflow obstruction caused bychronic bronchitis oremphysema; clinicaluse of the term indicates the presence ofchronicbronchitis and/or emphysema;includes asthma, chronicbronchiectasis,chronic bronchitis, and emphysema.
chylothorax a condition marked by lymphaticfluid in the pleuralspace caused by aleak in the thoracic duct.
cirrhosisVitamin K1 (AquaMephyton)high calorie, low sodiumdietsodium restriction w/ edemafluids restricted to decreaseasciteslate stage = ascites
CKD chronic kidney diseaseprior to hemodialysis lab=
hypocalcemia due tohyperphosphatemia, hyperkalemic &
hypernatremic
A client diagnosed with angina pectoris complains ofchest painwhile ambulating in the hallway. Whichaction should the nurseimplement first?
A. Support the client to a sitting position.B. Ask the client towalk slowly back to the room.C. Administer a sublingualnitroglycerin tablet.D. Provide oxygen via nasal cannula.
See AlsoHESI Health Assessment Exam Practice Questions - KnoowyPEDS HESI RN Case Studies With Practice Test - [PDF Document]The Priority Assessment For A Client With Marginal Abruptio Placentae Includes Fetal Status, Vital Signs,Hesi Study Guid - [DOC Document]A. Assist in safely repositioning andthen administer (C &D). Then theclient can be escorted back to theroom via wheelchairor stretcher (B).
A client diagnosed with chronic kidney disease (CDK) 2years agois regularly treated at a communityhemodialysis facility. Inassessing the client before hisscheduled dialysis treatment, whichelectrolyte imbalanceshould the nurse anticipate?
A. HypophosphatemiaB. HypocalcemiaC. HyponatremiaD.Hypokalemia
B. Hypocalcemia develops in CKDdue to chronichyperphosphatemianot (A). (C & D) incorrect you wouldfindhypernatremia andhyperkalemia
A client is placed on a mechanical ventilator following acerebralhemorrhage, and vecuronium bromide (Norcuron) 0.04mg/kgevery 12 hours IV is prescribed. What is the prioritynursingdiagnosis for this client?
A. Impaired communication related to paralysis ofskeletalmuscles.B. Hight risk or infection related to increasedICP.C. Potential for injury related to impaired lung expansion.D.Social isolation related to inability to communicate.
A. To increase the client's tolerance of theendotrachealintubation and/or mechanicalventilation, a skeletal-muscle relaxantsuch asvecuronium is usually prescribed. (A) is a seriousoutcomebecause the client cannot communicatehis/her needs. (D) is not asmuch of a priority. (B)infection is not related to ICP. (C) isincorrectbecause the ventilator will ensure that the lungsareexpanded.
A client who is receiving an ACE inhibitor for hypertensioncalls theclinic and reports the recent onset of a cough to thenurse. What actionshould the nurse implement?
A. Advise the client to come to the clinic immediately forfurtherassessment.B. Instruct the client to discontinue use of thedrug, and make anappointment at the clinic.C. Suggest that theclient lear to accept the cough as a side effect to anecessaryprescription.D. Encourage the client to keep taking the drug untilseen by the HCP.
D. Cough is a common s/e of ACE inhibitors and isnot anindication to discontinue the medication. (A)immediate evaluationis not needed. (B) anantihypertensive should not be stoppedabruptly. (C)is demeaning since the cough may be disruptive totheclient and other medications may produce resultswithout thes/e.
A client with alcohol-related liver disease is admittedto theunit. Which prescription should the nursequestion as possiblyinappropriate for the client?
A. Vitamin K1 (AquaMEPHYTON) 5 mg IM dailyB. High-calorie,low-sodium dietC. Fluid restriction to 1500 ml/dayD. Pentobarbital(Nembutal sodium) 50 mg atbedtime for rest
D. Sedatives such as Nembutal are contraindicatedfor clientswith liver damage and can have dangerousconsequences. (A) is oftenprescribed since normalclotting mechanism is damaged. (B) is neededtorestore energy. (C) Fluids are restricted to decreaseasciteswhich often accompanies cirrhosis,particularly in later stages ofthe disease.
A client with chronic asthma is admitted to postanesthesiacomplainingof pain at level 8 of 10, with a BP of 124/78, pulse of88 beats/min, andrespirations of 20 breaths/min. The postanesthesiarecoveryprescription is, "Morphine 2 to 4 mg IV push while inrecovery for painlevel over 5." What intervention should the nurseimplement?
A. Give the medication as prescribed to decrease the client'spain.B. Call the anesthesia provider for a different medication forpain.C. Use nonpharmacologic techniques before giving themedication.D. Reassess pain level in 30 Minutes and medicate if itremainselevated.
B. Call for a different medication becausemorphine andmeperidine (Demerol)have histamine-releasing narcotics andshould beavoided when a client hasasthma. (A) puts the client at riskforasthma attack. (C & D) disregard theclients prescription andpain relief.
A client with cirrhosis states that his disease wascause by ablood transfusion. What informationshould the nurse obtain first toprovide effectiveclient teaching?
A. The year the blood transfusion was receivedB. The amount ofalcohol the client drinksC. How long the client has had cirrhosisD.The client's normal coping mechanisms
A. The nurse should first verify the clientsexplanation (A)since it may be accuratedue to prior to 1990 blood was notscreenedfor Hep C and hep C can causecirrhosis. Not all cirrhosis is causediscaused by alcoholism (B) (C & D) provideuseful but lessrelevant information.
A client with hypertension has been receiving ramipril (Altace)5mg PO daily for 2 weeks and is scheduled to receive a dose at0900.At 0830 the client's blood pressure is 120/70. Which actionshouldthe nurse take?
A. Administer the dose as prescribed.B. Hold the dose andcontact the healthcare provider.C. Hold the dose and recheck theblood pressure in 1 hour.D. Check the healthcare provider'sprescription to clarify the dose.
A. The BP is WNL and indicates thatthe medication is working. (B& C)would be indicated if the BP was low(systole below 100).(D) is notrequired because the dose is withinmanufacture'srecommendations.
Coccyx Tailbone.
community-acquired pneumoniaa lower respiratory tract infectionofthe lung parenchyma with onset inthe community or during thefirst 2days of hospitalization.
compliance a measure of the ease of expansion ofthe lungs andthorax.
COPD contributing factor=smoking
cor pulmonalehypertrophy of the right side of theheart, with orwithout heart failure,
resulting from pulmonaryhypertension.
CPR just above the xiphoid process on thelower third of thesternum
crackleshort, low-pitched sounds consisting ofdiscontinuousbubbling caused by airpassing through airway intermittentlyoccludedby mucus, unstable bronchial wall,or fold of mucosa; evident oninspirationand, at times, expiration; similar sound toblowingthrough a straw under water.
Craniotomy Incision of the skull.
Cushing Syndrome
results from hypersecreationglucocorticoids in the adrenalcortexoften develope diabetes mellitus -monitor serum glucoselevelsgenerialized edemalow calorie, low carbohydrate, lowsodiumdiet
cystic fibrosisan autosomal recessive, multisystemdiseasecharacterized by alteredfunction of the exocrine glandsinvolvingprimarily the lungs,pancreas, and sweat glands.
Cystocele Hernia of the urinary bladder.
Debilitating anginal pain can be decreased in some clients bytheadministration of beta-blocking agents such as nadolol(Corgard). Whichclient requires the nurse to use extreme cautionwhen administeringCorgard?A. A 56-year-old air traffic controllerwho had bypass surgery 2 yearsago.B. A 47-year-old kindergartenteacher diagnosed with asthma 40 yearsagoC. A 52-year-oldunemployed stock broker who refuses treatment foralcoholismD. A60-year-old retired librarian who takes a diuretic dailyforhypertension.
B. asthma must be carefully monitoredbecause beta blockersbecause it caninduce cardiogenic shock and reducebronchodilationefforts. (A & D) thismedication is indicated and (C) it isnotcontraindicated.
deviated septum a deflection of the normally straightnasalseptum.
Diaphragm Muscular wall separating theabdominal and thoraciccavities.
diaphragmatic breathing breathing with the use of thediaphragmto achieve maximuminhalation and slow respiratory rate.
digitalis (Lanoxin)digoxin
cardiac glycosidecan build up toxic levels s/s anexoria,
nausea, vomiting, diarrhea,headache, fatigue
Disc A piece of cartilage betweenbackbones.
diverticulitit*hard ridgid abdomen & elevated WBC=peritonitis = medical emergency shouldbe reported to PCPimmediately
s/s left lower quadrant pain; elevatedtemperature; refusing toeat; nausea
DNA Genes are composed of?
dry powder inhaler dry powdered drug delivered byinhalation.
During admission of a patient diagnosed with non-small cellcarcinoma of the lung, the nurse questionsthe patient related to ahistory of which of thefollowing risk factors for this type ofcancer? (Selectall that apply.) A. Asbestos exposure B. Cigarettesmoking C. Exposure to uranium D. Chronic interstitial fibrosis
A,B,C Non-small carcinoma is associatedwith cigarette smokingand exposure toenvironmental carcinogens, includingasbestos anduranium. Chronicinterstitial fibrosis is associated withthedevelopment of adenocarcinoma of thelung.
During assessment of a 45-year-old patient withasthma, the nursenotes wheezing and dyspnea. Thenurse interprets that these symptomsare related towhich of the following pathophysiologic changes?A.Laryngospasm B. Overdistention of the alveoli C.Narrowing of theairway D. Pulmonary edema
C. Narrowing of the airwayNarrowingof the airway leads toreducedairflow, making it difficult for thepatient to breathe andproducing thecharacteristic wheezing.
During assessment of a client in the intensive care unit,thenurse notes that the client's breath sounds are clearuponauscultation, but jugular vein distention andmuffled heart soundsare present. Which interventionshould the nurse implement?
A. Prepare the client for a pericardial tap.B. Administerintravenous furosemide (Lasix).C. Assist the client to cough anddeep breathe.D. Instruct the client to restrict oral fluidintake.
A. The client is exhibiting symptoms ofcardiac tamponade thatresults inreduced cardiac output. Treatment ispericardial tap. (B)is not a treatment.(C) is not priority. (D) Fluids arefrequentlyincreased but this is not aspriority as (A).
During care of a patient with multiple myeloma, animportantnursing intervention is A. limiting activity to prevent pathologicfractures. B. assessing for changes in size and characteristicsoflymph nodes. C. maintaining a fluid intake of 3 to 4 L/day todilutecalcium load. D. administering narcotic analgesicscontinuously tocontrol bone pain.
C. maintaining a fluid intake of 3 to 4L/day to dilute calciumload. Adequatehydration must be maintained tominimize problems fromhypercalcemia.The goal of a urinary output of 1.5 to 2L/dayrequires an intake of 3 to 4 L/day.
During discharge teaching for a 65-year-old patientwithemphysema and pneumonia, which of thefollowing vaccines should thenurse recommend thepatient receive? A. S. aureus B. H. influenzaeC. Pneumococcal D. Bacille Calmette-Gurin (BCG)
C. Pneumococcal The pneumococcalvaccine is important forpatients witha history of heart or lung disease,recovering from asevere illness, age65 or over, or living in a long-termcarefacility.
During report, the nurse learns that a client with tumorlysissyndrome is receiving an IV infusion containing insulin.Whichassessment should the nurse complete first?
A. Review the client's history for diabetes mellitus.B. Observethe extremity distal to the IV site.C. Monitor the client's serumpotassium and blood glucose.D. Evaluate the client's oxygensaturation and breath sounds.
C. The client with tumor lysissyndrome mayexperiencehyperkalemia, therefor it is importantto monitor serumpotassium andblood glucose levels. (A, B, D) are notaspriority.
During the change of shift report, thecharge nurse reviews theinfusionsbeing received by the clients on theoncology unit. Theclient receivingwhich infusion should be seen first?
C. Has the highest risk for respiratorydepression and thereforshould beseen first. (A) Risk of hypotension.(B) Lowest risk. (D)Risk ofnephrotoxicity and phlebitis.
dyspneashortness of breath; difficultybreathing that may becaused bycertain heart conditions, strenuousexercise, oranxiety.
ECGU wave is positive deflectionfollowing theT wave oftenpresent in hypokalemia
tall spiked T wave, prolonged QTintervial, widening QRS complexare allsigns of hyperkalemia
elastic recoil the tendency for the lungs to recoil orreduce involume after beingstretched or expanded.
emphysemaan abnormal condition of the
pulmonary system, characterized byoverinflation and destructivechanges
in alveolar walls.
empyemaan accumulation of purulentexudates in a body cavity,especiallythe pleural space, as a result ofbacterial infection,such as pleurisyor tuberculosis.
Endoplasmic Reticulum Part of the cell where formationofproteins occurs.
epistaxis nosebleed
esophageal speech a method of swallowing air, trappingit in theesophagus, and releasing itto create sound.
esophagogastromyesophageal cancer
risk for infection = meticulious oralcare should be providedseveral times
a day prior to surgery
An excess of carbon dioxide in the blood causes anincreasedrespiratory rate and volume because CO2 A. displaces oxygen onhemoglobin, leading to adecreased PaO2. B. causes an increase inthe amount of hydrogen ionsavailable in the body. C. combines withwater to form carbonic acid, loweringthe pH of cerebrospinal fluid.D. directly stimulates chemoreceptors in the medulla toincreaserespiratory rate and volume.
C. combines with water to form carbonic acid, loweringthe pH ofcerebrospinal fluid. A combination of excessCO2 and H2O results incarbonic acid, which lowers thepH of the cerebrospinal fluid andstimulates an increasein the respiratory rate. Peripheralchemoreceptors in thecarotid and aortic bodies also respond toincreases inPaCO2 to stimulate the respiratory center. ExcessCO2does not increase the amount of hydrogen ions availablein thebody but does combine with the hydrogen of waterto form anacid.
A family member was taught to suction a client'stracheostomyprior to the client's discharge from thehospital. Which observationby the nurse indicates thatthe family member is capable ofcorrectly performing thesuctioning technique?
A. Turns on the continuous wall suction to -190 mm HgB. Insertsthe catheter until resistance or coughing occursC. Withdraws thecatheter while maintaining suctioningD. Re-clears the tracheostomyafter suctioning the mouth
B. indicates correct technique forperforming suctioning. Suctionpressureshould be between -80 and -120 (A). Thecatheter should bewithdrawn 1-2 cm at atime with intermittent suction (C).(D)introduces pathogens.
A female client with a nasogastric tube attached to lowsuctionstates that she is nauseated. The nurse assessesthat there has beenno drainage through the nasogastrictube in the last 2 hours. Whichaction should the nursetake first?
A. Irrigate the nasogastric tube with sterile normal saline.B.Reposition the client on her side.C. Advance the nasogastric tube 5cm.D. Administer an intravenous antiemetic as prescribed.
B. The priority is to determined if thetube is functioningcorrectly, whichwould relieve the client's nausea. Theleastinvasive intervention is to repositionthe client (B), should beattempted first,followed by (A & C) if these areunsuccessfulthen (D).
flail chest instability of the chest wall resultingfrom multiplerib fractures.
Following a patient's bone marrow aspiration, whichof thefollowing nursing interventions should a nurseanticipate? A.Application of firm pressure to the site B.Positioning the patientin a prone position C. Positioning the patient in a supine positionD. Application of a warm, moist compress to the site
A. Application of firm pressure to the site After abone marrowaspiration procedure, a nurse shouldapply pressure to theaspiration site until bleedingstops. Application of a warm, moistcompress will notalter the potential for bleeding. Positioningthepatient to assume a supine or prone position also willnotaddress the need to control bleeding from theaspiration site.
Following a supraglottic laryngectomy, the patient is taught howtouse the supraglottic swallow to minimize the risk of aspiration.Inteaching the patient about this technique, the nurse instructsthepatient to A. perform Valsalva maneuver immediately afterswallowing. B. breathe between each Valsalva maneuver and coughsequence. C. cough after swallowing to remove food from the top ofthe vocalcords. D. practice swallowing thin, watery fluids beforeattempting toswallow solid foods.
C. cough after swallowing to remove food from the top ofthevocal cords. A supraglottic laryngectomy involvesremoval of theepiglottis and false vocal cords, and theremoval of the epiglottisallows food to enter the trachea.Supraglottic swallowing requiresperformance of theValsalva maneuver before placing food in themouth andswallowing. The patient then coughs to remove food fromthetop of the vocal cords, swallows again, and thenbreathes after thefood has been removed from the vocalcords.
fremitus vibration of the chest wall producedbyvocalization.
gangrene necrosis/tissue deathpriority prevent infection
hemothorax accumulation of blood in the pleuralspace.
Hepatitis Bhealth care providers should have
Hep B vaccine;transmitted by fecal/oral
contamination
Histologist Person who studies tissues.
The home health nurse is assessing a male client being treatedforParkinson disease with levodopa-carbidopa (Sinemet). Thenurseobserves that he does not demonstrate any apparentemotionswhen speaking and rarely blinks. Which intervention shouldthenurse implement?
A. Perform a complete cranial nerve assessment.B. Instruct theclient that he may be experiencing medicationtoxicity.C. Documentthe presence of these assessment findings.D. Advise the client toseek immediate medical evaluation.
C. A mask-like expression and infrequentblinking are commonclinical features ofParkinsonism. The nurse shoulddocument thefindings. (A & D) are notnecessary. Signs of toxicity (B)aredyskinesia, hallucinations, and psychosis.
hospital-acquired pneumoniapneumonia occurring 48 hours or
longer after hospital admission andnot incubating at the timeof
hospitalization.
hypercalcemia positive trousseau sign = carpalspasm
hypercapniagreater than normal amounts of
carbon dioxide in the blood (PaCO2> 45 mm Hg); alsocalled
hypercarbia.
HyperkalemiaECG=tall spiked T wave, prolongedQT intervial,widening QRS complexare all signs of hyperkalemia;
tumor lysis syndrome
hyperreactivity an abnormal condition in whichresponses tostimuli are exaggerated.
hyperresponsivenessexcessive or exaggerated response toastimulus; in asthma leads tobronchoconstriction in responsetophysical, chemical, or pharmacologicstimuli.
Hypertrophy Excessive devolopment.
hypocapnia low arterial carbon dioxide pressure(PaCO2 < 35 mmHg); also calledhypocarbia.
Hypochondriac regions The upper lateral regions of theabdomen,beneath the ribs.
Hypoglossal (12th crainal nerve) difficulty chewing, talkingandswallowing
hypokalemiapatients on diureticswill change patients normal ECG= Uwave is positive deflection followingthe T wave often presentinhypokalemia
hypomagnesemiachronic alcholic
ie HR 160 BP 90/54 give IVmagnesium sulphate
prolonged QT intervial
If a health care provider is planning to transfuse apatient witha unit of packed red blood cells, which ofthe following solutionsshould the health careprovider hang with the transfusion? A. 5%dextrose in water B. 0.9% sodium chloride C. 5% dextrose in 0.9%sodium chloride D. 5%dextrose in lactated Ringer's solution
B. 0.9% sodium chloride The onlysolution appropriate foradministrationwith whole blood or blood products is0.9% sodiumchloride. The other optionsare not appropriate for use withbloodproducts.
If a nurse is assessing a patient whose recent bloodgasdetermination indicated a pH of 7.32 and respirationsaremeasured at 32 breaths/min, which of the following is themostappropriate nursing assessment? A. The rapid breathing iscausing the low pH. B. The nurse should sedate the patient to slowdown respirations. C. The rapid breathing is an attempt tocompensate for the low pH. D. The nurse should give the patient apaper bag to breathe into tocorrect the low pH.
C. The rapid breathing is an attempt to compensatefor the lowpH. The respiratory system influences pH(acidity) through controlof carbon dioxideexhalation. Thus, rapid breathing increases thepH.Breathing into a paper bag aids a patient whoishyperventilating; in respiratory alkalosis, it aids inloweringthe pH. The use of sedation can causerespiratory depression andhypoventilation, resultingin an even lower pH.
If a nurse is caring for an 80-year-old patient withatemperature of 100.4 F, crackles at the right lungbase, pain withdeep inspiration, and dyspnea, whichof the following orders is thenurse's priority? A.Sputum specimen for culture and sensitivity B.Codeine 15 mg orally every 6 hours as neededC. Incentive spirometerevery 2 hours while awake D. Amoxicillin (Amoxil) 500 mg orally 4times a day
A. Sputum specimen for culture and sensitivity The patientpresentswith signs of a respiratory infection. To initiate the mosteffectivetherapy, the health care prescriber must know thepathogencausing the infection. Therefore, the sputum specimen isthenurse's priority. If the antibiotic is administered beforethespecimen is obtained, the results of the culture might not beasaccurate and could impair the effectiveness of therapy. Afterthespecimen is obtained, the nurse can administer codeineforcoughing and begin the incentive spirometry to mobilizesecretionsand improve the patient's ability to expectorate thesecretions.
If a patient has pernicious anemia, the nurseshould provideinformation regarding A. frequent bouts of dyspnea. B. risksrelative to dehydration. C. deficiency of intrinsic factor. D. lackof any effective treatment for thiscondition.
C. deficiency of intrinsic factor.Pernicious anemia is a type ofanemiacaused by failure of absorption of vitaminB12 (cobalamin).The most commoncause is lack of intrinsic factor, aglucoproteinproduced by the parietalcells of the gastric lining.
If a patient states, "It's hard for me to breathe and Ifeelshort-winded all the time," what is the mostappropriate terminologyto be applied indocumenting this assessment by a nurse? A. Apnea B.Dyspnea C. Tachypnea D. Respiratory fatigue
B. Dyspnea Dyspnea is a subjective description reflectiveof thepatient's statement indicating difficulty inbreathing. Apnea refersto absence of breath or breathing.Tachypnea refers to an increasedrate of breathing,usually greater than 20 breaths per minute.Respiratoryfatigue is subjective and usually refers to thepatientexhibiting signs and symptoms associated with acomprehensiverespiratory assessment including laboriousbreathing, use ofaccessory muscles, and slowing ofrespirations.
If a patient with an uncuffed tracheostomy tube coughsviolentlyduring suctioning and dislodges thetracheostomy tube, a nurseshould first A. call the physician. B. attempt to reinsert thetracheostomy tube. C. position the patient in a lateral positionwith the neckextended. D. cover the stoma with a sterile dressingand ventilatethe patient with a manual bag-mask until thephysicianarrives.
B. attempt to reinsert the tracheostomytube.Retention suturesmay be grasped (if present)and the tracheostomy opening spread, ora hemostatmay be used to spread the opening. The obturatorisinserted into the replacement tube (one size smallerthan theoriginal tube), lubricated with salinesolution, and inserted intothe stoma at a 45-degreeangle to the neck. If the attempt issuccessful, theobturator tube should immediately be removed.
If a patient with arthritis develops iron-deficiency anemia, anurse should askabout the patient's use of A. alcoholic beverages.B. stool softeners and laxatives. C. caffeinated foods andbeverages. D. NSAIDs.
D. NSAIDs. NSAIDs decrease the level of vitamin C, which aidsinthe absorption of iron. These drugs also compete with folateandvitamin K and may cause gastritis. Excessive alcoholicbeverageconsumption can cause stomach irritation; alcohol would notbedirectly related to iron-deficiency anemia unless bleeding ulcersorgastritis were to occur. NSAID consumption, not stoolsoftenersand laxative use, would be suspect for iron-deficiencyanemia.Caffeinated foods and beverages can cause gastric irritationanddiscomfort but are not associated with iron-deficiencyanemia.
If a patient with blood type O Rh- is given AB Rh- blood,thenurse would expect A. the patient's Rh factor to react with theRBCs of thedonor blood. B. no adverse reaction because the patienthas noantibodies against the donor blood. C. the anti-A and anti-Bantibodies in the patient's bloodto hemolyze the donor blood. D.the anti-A and anti-B antibodies in the donor blood tohemolyze thepatient's blood.
C. the anti-A and anti-B antibodies in the patient's bloodtohemolyze the donor blood. A patient with O Rh+ blood has no A orBantigens on the red cell but does have anti-A and anti-Bantibodiesin the blood and has an Rh antigen. AB Rh- blood hasboth A and Bantigens on the red cell but no Rh antigen and noanti-A or anti-Bantibodies. If the AB Rh- blood is given to thepatient with O Rh+blood, the antibodies in the patient's blood willreact with theantigens in the donor blood, causing hemolysis ofthe donor cells.There will be no Rh reaction because the donorblood has no Rhantigen.
In assessing an older client with dementia forsundowningsyndrome, what assessment technique isbest for the nurse touse?
A. Observe for tiredness at the end of the day.B. Perform aneurologic exam and mental statusexam.C. Monitor for medicationside effects.D. Assess for decreased gross motor movement.
A. Sundowning syndrome is a pattern ofa*gitated behavior in theevening, believedto be associated with tiredness at the endof theday combined with fewer orientingstimuli, such as activitiesandinteractions. (B, C, & D) with not provideinformation aboutthis syndrome.
In older adults, infection after exposure to respiratory illnessismost likely to A. result in similar rates of infection as in theyounger adult. B. be easily prevented with the use of antibioticsafter beingexposed. C. result in serious lower respiratoryinfection related to weakenedrespiratory muscles and fewer cilia.D. be less serious because the older adult has less contactwithyounger children who are most likely to carry seriousinfections.
C. result in serious lower respiratory infectionrelated toweakened respiratory muscles and fewercilia. Changes in the olderadult respiratory systemmake older adults more susceptible toinfections thatcan be very serious and life threatening. Useofantibiotics to "prevent" lung infections is notrecommended and isineffective for viral infections.
In preparing the preoperative teaching plan for apatient who isto undergo a total laryngectomy, anurse should give highestpriority to the A. tracheostomy being in place for 2 to 3 days. B.patient's not being able to speak normally again. C. insertion of agastrostomy feeding tube duringsurgery. D. patient's not being ableto perform deep-breathingexercises.
B. patient's not being able to speak normally again. Patientswhohave a total laryngectomy have a permanent tracheostomy andwillneed to learn how to speak using alternative methods, such asanartificial larynx. The tracheostomy will be permanent toallownormal breathing patterns and air exchange. After surgery,thepatient's nutrition is supplemented with enteral feedings,andwhen the patient can swallow secretions, oral feedings canbegin.Deep-breathing exercises should be performed with the patientatleast every 2 hours to prevent further pulmonarycomplications.
In teaching the patient with COPD about the need forphysicalexercise, the nurse informs the patient that A. allpatients with COPD should be able to increase walkinggradually upto 20 min/day. B. a bronchodilator inhaler should be used torelieve exercise-induced dyspnea immediately after exercise. C.shortness of breath is expected during exercise but should returntobaseline within 5 minutes after the exercise. D. monitoring theheart rate before and after exercise is the bestway to determinehow much exercise can be tolerated.
C. shortness of breath is expected during exercise but shouldreturnto baseline within 5 minutes after the exercise.Shortness ofbreathusually increases during exercise, but the activity is notbeingoverdone if breathing returns to baseline within 5 minutesafterstopping. Bronchodilators can be administered 10 minutesbeforeexercise but should not be administered for at least 5minutes afteractivity to allow recovery. Patients are encouraged towalk 15 to 20minutes a day with gradual increases, but actualpatterns willdepend on patient tolerance. Dyspnea most frequentlylimitsexercise and is a better indication of exercise tolerancethan isheart rate in the patient with COPD.
In the case of pulmonary embolus from deep veinthrombosis, whichof the following actions should thenurse take first? A. Notify thephysician. B. Administer a nitroglycerin tablet sublingually. C.Conduct a thorough assessment of the chest pain. D. Sit the patientup in bed as tolerated and applyoxygen.
D. Sit the patient up in bed as tolerated andapply oxygen.Thepatient's clinical picture isconsistent with pulmonary embolus, andthefirst action the nurse takes should be toassist the patient. Forthis reason, the nurseshould sit the patient up as toleratedandapply oxygen before notifying the physician.
Ischemia Blood is held back from an area.
IV's infusions potential problemsmorphine, continous epidural=respiratory depressionmagnesium continous infusion=hypotensionvancomycin intermittent infusion =nephrotoxicity &phlebitit*
jaundiceserium amylase & lipase 2 timeshigher than normalindicatepancreatic injuryfrothy tea colored urineclay coloredstools complaints of puritis
Karyotype Picture of nuclear structures arrangedin numericalorder.
kidney stone strain all urine most importantencourage urine
lactulose (Cephulac)reduce blood ammonia by excreation
of ammonia by stools
2 -3 soft stools per day
Laryngectomy cuff should be inflated only prior tofeeding
Laryngectomy Removal of the voice box.
Larynx Structure in the trachea.
Leukocyte Eosinophil is a (an)
levodopa (Sinemet)Parkinsons Diseaselessen tremorsincreasesamount of levodopa to CNS(dopamine to the brain)s/stoxicity=dyskinesia,hallucinations, psychosis
Liver RUQ contain the _______.
lung abscess a pus-containing lesion of the lungparenchyma thatresults in a cavityformed by necrosis of lung tissue.
Lymphocyte A blood cell that produces antibodies.
Magnesium Sulphatehypomagnesemiareccomended for torsadesdepointes aform of polymorphic ventricaltackycardia associated withaprolonged QT intervial that occurswith hypomagnesemia
A male client who has never smoked but has hadCOPD for the past5 years is now being assessed forcancer of the lung. The nurseknows that he is mostlikely to develop which type of lungcancer?
A. AdenocarcinomaB. Oat-cell carcinomaC. Malignant melanomaD.Squamous-cell carcinoma
A. is the only lung cancer not relatedto cigarette smokingrelated to lungscarring and fibrosis from preexistingpulmonarydiseases such as TB andCOPD. (B& D) are related tosmoking. (C)is a skin cancer
A male client with arterial peripheral vasculardisease (PVD)complains of pain in his feet. Whichinstruction should the nursegive to the UPA toquickly relieve the client's pain?
A. Help the client to dangle his legs. B. Apply compressionstockings.C. Assist with passive leg exercises.D. Ambulate threetimes daily.
A. A client who has arterial PVD may benefit from adependentposition which can be achieved bydangling by improving blood flowand relieving pain.(B) is indicated for venous insufficiency and(C) isindicated for bed rest. (D) is indicated tofacilitatecollateral circulation and may improve longtermcomplaints of pain.
Malignant myeloma Tumor of bone marrow.
mechanical receptorsreceptors located in lungs, upperairways,chest wall, and diaphragmthat are stimulated by irritants,musclestretching, and alveolar walldistortion.
Mediastinum The space in the chest between thelungs.
meniere syndrome (8th crainalnerve)
tinnitus, vertigo, eharing difficulties
Metabolism Sum of the chemical processes in acell.
metered-dose inhaler aerosolized drug delivered in aspecificamount by activating theinhaler or by inhaling.
methotrexate (Mexate)immunosuppressant
can cause bone marrow depressionrheumatoid arthritis
lab=hemaglobin decrease =adverseside effect
Mitochondria Part of a cell where catabolismprimarilyoccurs.
The most appropriate position to assist a patient withchronicobstructive pulmonary disease (COPD) who is havingdifficultybreathing would be a A. high Fowler's position without apillow behind the head. B. semi-Fowler's position with a singlepillow behind the head. C. right side-lying position with the headof the bed at 45 degrees'elevation. D. sitting upright and forwardposition with arms supported on anover-the-bed table.
D. sitting upright and forward position with armssupported on anover-the-bed table.Sitting uprightand leaning forward with armssupported on an over-the-bed table would be of most help to thispatient,because it allows for expansion of the thoracic cage inallfour directions (front, back, and two sides).
Myelogram X-ray record of the spinal cord.
nadolol (Corgard)
beta blockerdibilatating anginal painbypass surgery patientsusewith diuretic for hypertensionuse extreme caution withrespiratoryproblems (asthma) and congestive heartfailure
nasal polypsbenign mucous membrane massesthat form slowly inresponse torepeated inflammation of the sinus ornasal mucosa andproject into thenasal cavity.
Necr/o Death
neuro function altered neuro function =
neurogenic bladder infection - from stasis of urineandsubsuquent catheterization
NG Tube no drainage in 2 hoursclient nausated = repositionclient onside
normocapnia normal arterial carbon dioxidepressure (PaCO2 35 to45 mm Hg).
The nurse assesses a patient withshortness of breath forevidence of long-standing hypoxemia by inspecting:A. Chestexcursion B. Spinal curvatures C. The respiratory patternD. Thefingernail and its base
D. The fingernail and its base Clubbing, asign of long-standinghypoxemia, isevidenced by an increase in the anglebetween the baseof the nail and thefingernail to 180 degrees or more,usuallyaccompanied by an increase in the depth,bulk, and sponginessof the end of the finger.
The nurse assesses a postoperative client. Oxygen isbeingadministered at 2 L/min and a saline lock is inplace.Assessment shows cool, pale, moist skin. The client isveryrestless and has scant urine in the urinary drainage bag.Whatintervention should the nurse implement first.
A. Measure urine specific gravity.B. Obtain IV fluids forinfusion protocol.C. Prepare for insertion of a central venouscatheter.D. Auscultate the client's breath sounds.
B. The client is at risk forhypovolemic shock and isexhibitingearly signs. Start IV to restore tissueperfusion. (A, C,D) are all importantbut less of a priority.
The nurse determines that a patient is experiencingcommonadverse effects from the inhaledcorticosteroid beclomethasone(Beclovent) afternoting which of the following? A. Adrenocorticaldysfunction and hyperglycemia B. Elevation of blood glucose andcalcium levelsC. Oropharyngeal candidiasis and hoarseness D.Hypertension and pulmonary edema
C. Oropharyngeal candidiasis and hoarsenessOropharyngealcandidiasis and hoarseness arecommon adverse effects from the useof inhaledcorticosteroids because the medication can leadtoovergrowth of organisms and local irritation if thepatient doesnot rinse the mouth following each dose.
The nurse determines that the patient is notexperiencing adverseeffects of albuterol (Proventil)after noting which of the followingpatient vitalsigns? A. Oxygen saturation 96% B. Respiratory rate of18 C. Temperature of 98.4 F D. Pulse rate of 76
D. Pulse rate of 76 Albuterol is a 2-agonist that can sometimescause adversecardiovascular effects. These wouldinclude tachycardiaand angina. A pulserate of 76 indicates that the patient didnotexperience tachycardia as an adverseeffect.
The nurse determines that the patient understoodmedicationinstructions about the use of a spacer device when takinginhaledmedications after hearing the patient state which of thefollowingas the primary benefit? A. "Now I will not need to breathein as deeply when taking theinhaler medications." B. "This devicewill make it so much easier and faster to take myinhaledmedications." C. "I will pay less for medication because it willlast longer." D. "More of the medication will get down into mylungs to help mybreathing."
D. "More of the medication will getdown into my lungs to helpmybreathing." A spacer assists moremedication to reach the lungs,withless being deposited in the mouthand the back of thethroat.
A nurse establishes the presence of a tensionpneumothorax whenassessment findings reveal a(n) A. absence of lung sounds on theaffected side. B. inability to auscultate tracheal breath sounds.C. deviation of the trachea toward the side oppositethepneumothorax. D. shift of the point of maximal impulse (PMI) totheleft, with bounding pulses.
C. deviation of the trachea toward the side oppositethepneumothorax. Tension pneumothorax is causedby rapid accumulationof air in the pleural space,causing severely high intrapleuralpressure. Thisresults in collapse of the lung, and themediastinumshifts toward the unaffected side, which issubsequentlycompressed.
The nurse evaluates that a patient is experiencing theexpectedbeneficial effects of ipratropium (Atrovent)after noting which ofthe following assessmentfindings? A. Increased peak flow readingsB. Increased level of consciousness C. Decreased sputum productionD. Increased respiratory rate
A. Increased peak flow readings.Ipratropium is a bronchodilatorthat
should lead to increased PEFRs.
The nurse evaluates that discharge teaching for a patienthospitalizedwith pneumonia has been most effective when the patientstates whichof the following measures to prevent a relapse? A. "Iwill increase my food intake to 2400 calories a day to keepmyimmune system well." B. "I must use home oxygen therapy for 3months and then will have achest x-ray to reevaluate." C. "I willseek immediate medical treatment for any upperrespiratoryinfections." D. "I should continue to do deep-breathingand coughing exercises for atleast 6 weeks."
D. "I should continue to do deep-breathing and coughingexercisesfor at least 6 weeks." It is important for thepatient to continuewith coughing and deep breathingexercises for 6 to 8 weeks untilall of the infection hascleared from the lungs. A patient shouldseek medicaltreatment for upper respiratory infections that persistformore than 7 days. Increased fluid intake, not caloricintake, isrequired to liquefy secretions. Home O2 is not arequirement unlessthe patient's oxygenation saturation isbelow normal.
The nurse evaluates that nursing interventions topromote airwayclearance in a patient admitted withCOPD are successful based onwhich of the followingfindings? A. Absence of dyspnea B. Improvedmental status C. Effective and productive coughing D. PaO2 withinnormal range for the patient
C. Effective and productive coughingThe issue of the question isairwayclearance, which is most directlyevaluated as successful ifthe patientcan engage in effective andproductive coughing.
The nurse evaluates that teaching for the patient withirondeficiency anemia has been effective when thepatient states A. "Iwill need to take the iron supplementsthe rest of my life." B. "Iwill increase my dietary intake of milk and milkproducts." C. "Ishould increase my activity to increase my aerobiccapacity." D. "Ishould take the iron for several months after myblood isnormal."
D. "I should take the iron for several months after myblood isnormal." To replace the body's iron stores, ironsupplements shouldbe continued for 2 to 3 months afterthe Hb level returns to normal,but if the cause of the irondeficiency is corrected, thesupplements do not need to betaken for a lifetime. Milk and milkproducts are poorsources of dietary iron. Activity should begraduallyincreased as Hb levels return to normal becauseaerobiccapacity can be increased when adequate Hb is available.
The nurse identifies the nursing diagnosis ofactivityintolerance for a patient with asthma. The nurseassessesfor which of the following etiologic factor forthis nursingdiagnosis in patients with asthma? A. Anxiety and restlessness B.Effects of medications C. Fear of suffocation D. Work ofbreathing
D. Work of breathingWhen the patient doesnot have sufficient gasexchange to engage inactivity, the etiologic factor is often theworkof breathing. When patients with asthma donot have effectiverespirations, they use allavailable energy to breathe and havelittleleft over for purposeful activity.
The nurse is assessing a 75-year-old male client forsymptoms ofhyperglycemia. Which symptom ofhyperglycemia is an older adult mostlikely toexhibit?
A. PolyuriaB. PolydipsiaC. Weight lossD. Infection
D. S/Sx of hyperglycemia in older adultsmay include fatigue,infection, andneuropathy (such as sensory changes).(A, B, C) areclassic symptoms and maybe absent in the older adult.
The nurse is assessing a client who presents withjaundice. Whichassessment finding is the mostsignificant indication that furtherfollow up is needed?
A. Urine specific gravity of 1.03 with a urine output of500 mlin 8 hoursB. Frothy, tea-colored urineC. Clay-colored stools andcomplaints of pruritusD. Serum amylase and lipase levels that aretwice theirnormal levels
D. Obstructive cholelithiasis andalcoholism are the two majorcauses ofpancreatitis, and an elevated serumamylase and lipaseindicate pancreaticinjury. (A) is a normal finding. (B & C)areexpected findings for jaundice.
The nurse is assigned to care for a patient in theemergencydepartment admitted with an exacerbation of asthma. Thepatienthas received a -adrenergic bronchodilator andsupplementaloxygen. If the patient's condition does not improve,the nurseshould anticipate which of the following is likely to bethe next stepin treatment? A. Pulmonary function testing B.Systemic corticosteroids C. Biofeedback therapy D. Intravenousfluids
B. Systemic corticosteroids Systemiccorticosteroids speed theresolution ofasthma exacerbations and areindicated if the initialresponse to the-adrenergic bronchodilator isinsufficient.
The nurse is assigned to care for a patient who hasanxiety andan exacerbation of asthma. Which of thefollowing is the primaryreason for the nurse tocarefully inspect the chest wall of thispatient? A. Observe for signs of diaphoresis B. Allow time to calmthe patient C. Monitor the patient for bilateral chest expansion D.Evaluate the use of intercostal muscles
D. Evaluate the use of intercostal musclesThe nurse physicallyinspects the chestwall to evaluate the use ofintercostal(accessory) muscles, which gives anindication of thedegree of respiratorydistress experienced by the patient.
The nurse is assisting a patient to learn self-administrationofbeclomethasone two puffs inhalation q6hr. The nurse explainsthatthe best way to prevent oral infection while taking thismedicationis to do which of the following as part of the self-administrationtechniques? A. Chew a hard candy before the first puff ofmedication. B. Ask for a breath mint following the second puff ofmedication. C. Rinse the mouth with water before each puff ofmedication. D. Rinse the mouth with water following the second puffofmedication.
D. Rinse the mouth with water followingthe second puff ofmedication. Thepatient should rinse the mouth with waterfollowingthe second puff of medicationto reduce the risk of fungalovergrowthand oral infection.
The nurse is caring for a 73-year-old patient who underwent alefttotal knee arthroplasty. On the third postoperative day, thepatientcomplains of shortness of breath, slight chest pain, andthat"something is wrong." Temperature is 98.4o F, bloodpressure130/88, respirations 36, and oxygen saturation 91% on roomair.Which of the following should the nurse first suspect astheetiology of this episode? A. Septic embolus from the knee jointB. Pulmonary embolus from deep vein thrombosis C. New onset ofangina pectoris D. Pleural effusion related to positioning in theoperating room
B. Pulmonary embolus from deep veinthrombosis The patientpresents theclassic symptoms of pulmonary embolus:acute onset ofsymptoms, tachypnea,shortness of breath, and chest pain.
The nurse is caring for a client with a chest tube to watersealdrainage that was inserted 10 days ago because of aruptured bullaeand pneumothorax. Which findingshould the nurse report to thehealthcare provider beforethe chest tube is removed?A. Tidal ofwater in the water seal chamberB. Bilateral muffled breath soundsat basesC. Temperature of 101 degrees FD. Absence of chest tubedrainage for 2 days.
A. Tidal in the water seal chamber shouldbe reported to the HPCto show that thechest tube is working properly. (B) mayindicatehypoventilation from the chesttube and usually improves when thetubeis removed. (C) indicates infection (D) isan expectedfinding.
The nurse is caring for a critically ill client with cirrhosisofthe liver who has a nasogastric tube draining brightred blood. Thenurse notes that the client's serumhemoglobin and hematocrit aredecreased. Whatadditional change in lab data should the nurseexpect?
A. Increased serum albumin B. Decreased serum creatinineC.Decreased serum ammoniaD. Increased liver function tests
C. The breakdown of glutamine in the intestine andthe increasedactivity of colonic bacteria from thedigestion of proteinsincreases the ammonia levels inthe clients with advanced liverdisease, so removal ofblood, a protein source, from the intestinesresults inreduced ammonia. (A, B, D) will not besignificantlyimpacted by the removal of blood.
The nurse is caring for a patient admitted to the hospitalwithpneumonia. Upon assessment, the nurse notes atemperature of 101.4F, a productive cough with yellowsputum and a respiratory rate of20. Which of thefollowing nursing diagnosis is most appropriatebasedupon this assessment? A. Hyperthermia related toinfectiousillness B. Ineffective thermoregulation related to chilling C.Ineffective breathing pattern related to pneumonia D. Ineffectiveairway clearance related to thick secretions
A. Hyperthermia related to infectious illness Becausethe patienthas spiked a temperature and has adiagnosis of pneumonia, thelogical nursing diagnosisis hyperthermia related to infectiousillness. There isno evidence of a chill, and her breathing patterniswithin normal limits at 20 breaths per minute. Thereis noevidence of ineffective airway clearance fromthe information givenbecause the patient isexpectorating sputum.
The nurse is caring for a patient who is to receive atransfusionof two units of packed red blood cells. Afterobtaining the firstunit from the blood bank, the nursewould ask which of the followinghealth team members inthe nurses' station to assist in checking theunit beforeadministration? A. Unit secretary B. Another registerednurse C. A physician's assistant D. A phlebotomist
B. Another registered nurseBeforehanging a transfusion, theregisterednurse must check the unit withanother RN or with alicensedpractical (vocational) nurse,depending on agencypolicy.
The nurse is caring for a patient with an acuteexacerbation ofasthma. Following initial treatment,which of the following findingsindicates to the nursethat the patient's respiratory status isimproving? A. Wheezing becomes louder B. Vesicular breath soundsdecrease C. Aerosol bronchodilators stimulate coughing D. The coughremains nonproductive
A. Wheezing becomes louder Theprimary problem during anexacerbationof asthma is narrowing of the airway andsubsequentdiminished air exchange. Asthe airways begin to dilate, wheezinggetslouder because of better air exchange.
The nurse is caring for a patient with COPD andpneumonia who hasan order for arterial blood gasesto be drawn. Which of thefollowing is the minimumlength of time the nurse should plan tohold pressureon the puncture site? A. 2 minutes B. 5 minutes C. 10minutes D. 15 minutes
B. 5 minutes Following obtaining an arterial bloodgas, the nurseshould hold pressure on the puncturesite for 5 minutes by the clockto be sure thatbleeding has stopped. An artery is an elasticvesselunder higher pressure than veins, and significantblood lossor hematoma formation could occur if thetime is insufficient.
The nurse is caring for a postoperative patient with suddenonset ofrespiratory distress. The physician orders a STATventilation-perfusion scan. Which of the following explanationsshould thenurse provide to the patient about the procedure? A. Thistest involves injection of a radioisotope to outline thebloodvessels in the lungs, followed by inhalation of a radioisotopegas. B. This test will use special technology to examine crosssections ofthe chest with use of a contrast dye. C. This test willuse magnetic fields to produce images of the lungsand chest. D.This test involves injecting contrast dye into a bloodvessel tooutline the blood vessels of the lungs.
A. This test involves injection of a radioisotope tooutline theblood vessels in the lungs, followed byinhalation of a radioisotopegas.A ventilation-perfusion scan has two parts. In theperfusionportion, a radioisotope is injected into the blood andthepulmonary vasculature is outlined. In theventilation part, thepatient inhales a radioactive gasthat outlines the alveoli.
The nurse is completing an admission inter for a clientwithParkinson disease. Which question will provideadditioninformation about manifestations the client is likely toexperience?
A. "Have you ever experienced and paralysis of your arms orlegs?"B. " Do you have frequent blackout spells?"C. "Have you everbeen 'frozen' in one spot, unable to move?"D. "Do you haveheadaches, especially ones with throbbing pain?"
C. Parkinson clients frequentlyexperience difficulty ininitiating,maintaining, and performing motoractivities. They mayeven experiencebeing rooted, unable to move. (A, B, D)Does nottypically occur in Parkinson.
The nurse is evaluating whether a patient understandshow tosafely determine whether a metered dose inhaleris empty. The nurseinterprets that the patientunderstands this important informationto preventmedication underdosing when the patient describeswhichmethod to check the inhaler? A. Place it in water to see if itfloats. B. Shake the canister while holding it next to the ear. C.Check the indicator line on the side of the canister. D. Keep trackof the number of inhalations used.
D. Keep track of the number of inhalations used. It isno longerappropriate to see if a canister floats inwater or not as researchhas demonstrated this is notaccurate. The best method to determinewhen toreplace an inhaler is by knowing the maximum puffsavailableper MDI and then replacing when thoseinhalations have beenused.
The nurse is interviewing a client who istakinginterferon-alfa-2a (Roferon-A) and ribavirin(Virazole)combination therapy for hepatitis C. The clientreportsexperiencing overwhelming feelings of depression. Whatactionshould the nurse implement first?
A. Recommend mental health counseling.B. Review the medicationsactions and interactions.C. Assess for the client's daily activitylevel.D. Provide information regarding a support group.
B. Alpha-interferon and ribavirincombination therapy cancausesevere depression. (A, B, C) may beimplemented afterphysiologicalaspect of the situation are assessed.
The nurse is observing an unlicensed assistive personnel(UPA)who is performing morning care for a bedfastclient with Huntingtondisease. Which care measure ismost important for the nurse tosupervise?
A. Oral careB. BathingC. Foot careD. Catheter care
A. A client with Huntington diseaseexperiences problems withmotorskills such as swallowing and is athigh risk for aspiration.(B, C, D) donot pose life-threateningconsequences.
A nurse is performing assessment for a patientdiagnosed withchronic obstructive pulmonarydisease (COPD). Which of the followingfindingsshould the nurse expect to observe? A. Nonproductive coughB. Prolonged inspiration C. Vesicular breath sounds D. Increasedanterior-posterior chest diameter
D. Increased anterior-posterior chest diameter Anincreasedanterior-posterior diameter is a compensatorymechanism experiencedby patients with COPD and iscaused by air-trapping. Patients withCOPD have aproductive cough, often expectorating copious amountsofsputum. Because of air-trapping, patients with COPDexperience aprolonged expiration because the rate of gason exhalation takeslonger to escape. Chest auscultationfor patients with COPD oftenreveals wheezing, crackles,and other adventitious breathsounds.
The nurse is performing hourly neurological check for aclientwith a head injury. Which new assessment findingwarrants the mostimmediate intervention by the nurse?
A. A unilateral pupil that is dilated and nonreactive tolight.B.Client cries out when awakened by a verbal stimulus.C. Clientdemonstrates a loss of memory to the eventsleading up to theinjury.D. Onset of nausea, headache, and vertigo.
A. Any changes in pupil size andreactivity is an indication ofincreasingICP and should be reported immediately.(B) is normal forbeing awakened. (C &D) are common manifestations of headinjuryand less of an immediacy than (A).
The nurse is planning the care for a client who is admitted withthesyndrome of inappropriate antidiuretic hormone secretion(SIADH).Which interventions should the nurse include in thisclient's planof care? (Select all that apply.)
A. Salt-free dietB. Quiet environmentC. Deep tendon reflexassessmentsD. Neurologic checksE. Daily weightsF. Unrestrictedintake of free water
B, C, D, E.
SIADH results in water retention and dilutionalhyponatremia,which causes neurologic change when serum sodiumlevels areless than 115 mEq/L. The nurse should maintain aquietenvironment (B) to prevent overstimulation that can lead toperiodsof disorientation, assess deep tendon reflexes (C) andneurologicchecks (D) to monitor for neurologic deterioration. Dailyweights(E) should be monitored to assess for fluid overload: 1 kgweightgain equals 1 L of fluid retention, which further dilutesserumsodium levels. (A and F) contribute to dilutionalhyponatremia.
A nurse is preparing to establish oxygen therapy for a patientwithCOPD, and the physician's prescription reads "oxygen pernasalcannula at 5 L per minute." Which of the following actionsshouldthe nurse take? A. Administer the oxygen as prescribed. B.Call the physician andquestion the correct flow rate of the oxygen.C. Establish the oxygen as prescribed and obtain an ABG. D. Changethe delivery device from a nasal cannula to a simpleoxygenmask.
B. Call the physician and question the correct flow rate of theoxygen.The nurse should call the physician immediately and questionthe flowrate for delivery of the oxygen before implementation.Oxygen is usedcautiously in patients with COPD because oflongstanding hypoxemiaserving as the respiratory drive mechanism.If high levels of oxygen areadministered, the respiratory drive canbe obliterated. Changing thedevice to a simple oxygen mask mayalter the oxygen concentrationbeing delivered to the patient andwill further enhance the obliterationof the patient's respiratorydrive. Obtaining an ABG sample is not apriority at this time, andthe action does not address the validity of theprescribed oxygendosing for the patient.
A nurse is providing care to an adult female patientand observesthat the Hb laboratory analysis result is9 g/dl. Based on thisfinding, the nurse should expectto observe A. dyspnea. B.bradycardia. C. warm, dry skin. D. activity tolerance withoutcomplaint of fatigue.
A. dyspnea.Hb levels are used to determine the severity ofanemia.Patients with moderate anemia (Hb 6 to 10 g/dL) may sufferfromdyspnea, palpitations, diaphoresis with exertion, andchronicfatigue. Patients who are anemic usually have cool skinrelated tocompensatory mechanism of mild vasoconstriction. Patientswhoare anemic experience tachycardia because of increaseddemandsplaced on the heart to meet overall metabolic requirements.Activitytolerance without complaint is not correct because patientswithanemic conditions fatigue readily.
A nurse is reviewing the hematologic test results fora patientin whom the hematocrit (Hct) is reported ata reading of 30%. Basedon this result, the nurseshould interpret that the patient A. issusceptible to bleeding disorders. B. has fewer red blood cellsthan normal. C. isexperiencing an inflammatory response. D. isexperiencing an acute hemolytic crisis.
B. has fewer red blood cells than normal.The Hct is the measureofthe volume of red blood cells in whole blood expressed asapercentage. This test is useful in the diagnosis ofanemia,polycythemia, and abnormal hydration states. Patients whoaresusceptible to bleeding disorders likely will have a lowplateletcount. The inflammatory response may best be evaluatedbyexamination of results that include the white blood cell countwithdifferential analysis. Acute hemolytic crisis develops inpatientsreceiving blood components in which incompatibility occursor inpatients with bleeding disorders or conditions that promotecellulardamage, such as damage associated with shock.
The nurse is reviewing the routine medications taken by aclientwith chronic angle closure glaucoma. Whichmedicationprescription should the nurse question?
A. An antianginal with a therapeutic effect of vasodilation.B.An anticholinergic with a side effect of pupillary dilation.C. Anantihistamine with a side effect of sedation.D. A corticosteroidwith a side effect of hyperglycemia.
B. Clients with angle closure glaucomashould not takemedications that dilatethe pupil (B) because this canprecipitateacute and severely increased intraocularpressure. (A, C,D) do not causeincreased intraocular pressure, which isthe primaryconcern.
The nurse is scheduled to give a dose of ipratropiumbromide bymetered dose inhaler. The nurse wouldadminister the right drug byselecting the inhalerwith which of the following trade names? A.Vanceril B. Pulmicort C. AeroBid D. Atrovent
D. Atrovent The trade or brand namefor ipratropium bromide,an
anticholinergic medication, isAtrovent.
The nurse is scheduled to give a dose of salmeterol bymetereddose inhaler (MDI). The nurse wouldadminister the right drug byselecting the inhalerwith which of the following trade names? A.Vanceril B. Serevent C. AeroBid D. Atrovent
B. Serevent The trade or brand namefor salmeterol, anadrenergicbronchodilator, is Serevent.
The nurse is teaching a patient how to self-administeripratropium(Atrovent) via a metered dose inhaler. Which of thefollowinginstructions given by the nurse is most appropriate tohelp thepatient learn proper inhalation technique? A. "Avoidshaking the inhaler before use." B. "Breathe out slowlybeforepositioning the inhaler." C. "After taking a puff, hold the breathfor 30 seconds beforeexhaling." D. "Using a spacer should beavoided for this type of medication."
B. "Breathe out slowly before positioningthe inhaler." It isimportant to breatheout slowly before positioning the inhaler.Thisallows the patient to take a deeperbreath while inhaling themedication thusenhancing the effectiveness of the dose.
The nurse is teaching a patient who is to undergo bonemarrowaspiration. Which of the following statements made by thenursewould indicate correct instruction regarding the site fortheaspiration procedure? A. "The health care provider will performthe aspiration by needleto the femur." B. "The health care providerwill perform the aspiration by needleto the scapula." C. "Thehealth care provider will perform theaspiration by needle to theantecubital fossa." D. "The health care provider will perform theaspiration by needleto the posterior iliac crest."
D. "The health care provider will perform theaspiration byneedle to the posterior iliac crest."Bone marrow samples arecommonly taken from theposterior iliac crest or, as an alternative,the sternummay be aspirated. These sites provide relative easeinaccessing the bone marrow via the biopsy needle. Theantecubitalfossa, femur, and scapula do not allowaccess to bone marrow whilealso providing reducedrisk of harm to the patient.
A nurse is working on a respiratory care unit where manyof thepatients are affected by asthma. Which of thefollowing actions bythe nurse would most likely increaserespiratory difficulty for thepatients? A. Wearing perfume to work B. Encouraging patients toambulate daily C. Allowingthe patients to eat green leafyvegetables D. Withholding antibiotic therapy until culturesareobtained
A. Wearing perfume to work People with asthma should avoidextrinsicallergens and irritants (e.g., dust, pollen, smoke,certain foods, colognesand perfumes, certain types of medications)because their airwaysbecome inflamed, producing shortness ofbreath, chest tightness, andwheezing. Many green leafy vegetablesare rich in vitamins, minerals,and proteins, which incorporatehealthy lifestyle patterns into thepatients' daily living routines.Routine exercise is a part of a prudentlifestyle, and for patientswith asthma the physical and psychosocialeffects of ambulation canincorporate feelings of well-being, strength,and enhancement ofphysical endurance. Antibiotic therapy is alwaysinitiated aftercultures are obtained so that the sensitivity to theorganism can bereadily identified.
The nurse know that a client taking diuretics must beassessedfor the development of hypokalemia, and thathypokalemia will createchanges in the client's normalECG tracing. Which ECG change wouldbe an expectedfinding in the client with hypokalemia?
A. Tall, spiked T wavesB. A prolonged QT intervalC. A wideningQRS complexD. Presence of a U wave
D. A U wave is a positive deflectionfollowing the T wave and isoftenpresent with hypokalemia. A, B, Cindicate hyperkalemia.
The nurse know that normal lab values expected for an adult mayvary in anolder client. Which data would the nurse expect to findwhen reviewinglaboratory values of an 80-year-old man who is ingood overall health.
A. Complet blood count reveals increased WBC and decreased RBCcounts.B. Chemistries reveal an increased serum bilirubin withslightly increased liverenzymes.C. Urinalysis reveals slightprotein in the urine and bacteriuria with pyuria.D. Serumelectrolytes reveal a decreased sodium level with anincreasedpotassium level.
C. In older adults the protein found inurine is slightly risenas a result of kidneychanges or subclinical UTIs and theclientfrequently experiencesasymptomatic bacteriuria and pyuria asaresult of incomplete bladder emptying.(A, B, D) are not normalfindings.
The nurse notes a physician's order written at 10:00 AMfor 2units of packed red blood cells to be administered toa patient whois anemic secondary to chronic blood loss.If the transfusion ispicked up at 11:30, the nurse shouldplan to hang the unit no laterthan which of the followingtimes? A. 11:45 AM B. 12:00 noon C.12:30 PM D. 3:30 PM
B. 12:00 noon The nurse must hangthe unit of packed red bloodcellswithin 30 minutes of signing themout from the blood bank
The nurse notices clear nasal drainage in a patientnewlyadmitted with facial trauma, including a nasalfracture. The nurseshould: A. test the drainage for the presence of glucose. B.suction the nose to maintain airway clearance. C. document thefindings and continue monitoring. D. apply a drip pad and reassurethe patient this isnormal.
A. test the drainage for the presence ofglucose. Clear nasaldrainage suggestsleakage of cerebrospinal fluid (CSF). Thedrainageshould be tested for thepresence of glucose, which wouldindicatethe presence of CSF.
The nurse observes ventricular fibrillation ontelemetry and uponentering the clients bathroomfinds the client unconscious on thefloor. Whatintervention should the nurse implement first?
A. Administer an antidysrhythmic medication.B. Startcardiopulmonary resuscitation.C. Defibrillate the client at 200joules.D. Assess the client's pulse oximetry.
B. Ventricular fibrillation is a life-threatening dysrhythmiaand CPRshould be started immediately. A & Care appropriate butB is the priority.D does not address the seriousness ofthesituation.
The nurse plans to help an 18-year-old developmentally disabledfemale clientambulate on the first postoperative day. When thenurse tells her it is time toget out of bed, the client becomesangry and yells at the nurse. "Get out ofhere! I'll get up when I'mready." Which response should the nurse provide?
A. "Your healthcare provider has prescribed ambulation on thefirstpostoperative day."B. "You must ambulate to avoid seriouscomplications that are much morepainful."C. "I know how you feel;you're angry about having to do this, but it isrequired."D. "I'llbe back in 30 minutes to help you get out of bed and walk aroundtheroom."
D. Returning in 30 minutes provides acooling off period, isfirm, direct,nonthreatening, and avoids argumentwith the client. Bis threatening. C.assumes what the client is feeling. A.avoids thenurse's responsibility toambulate the client.
The nurse receives a physician's order to transfuse fresh frozenplasma to apatient suffering from an acute blood loss. Which of thefollowing proceduresis most appropriate for infusing this bloodproduct? A. Hand the fresh frozen plasma as a piggyback to a newbag of primary IVsolution without KCl. B. Infuse the fresh frozenplasma as rapidly as the patient will tolerate. C. Hang the freshfrozen plasma as a piggyback to the primary IV solution. D. Infusethe fresh frozen plasma as a piggyback to a primary solutionofnormal saline.
B. Infuse the fresh frozen plasma as rapidly as thepatient willtolerate. The fresh frozen plasma shouldbe administered as rapidlyas possible and should beused within 2 hours of thawing. Freshfrozen plasmais infused using any straight-line infusion set.Anyexisting IV should be interrupted while the freshfrozen plasmais infused, unless a second IV line hasbeen started for thetransfusion.
The nurse reviews pursed lip breathing with a patient newlydiagnosedwith emphysema. The nurse reinforces that this techniquewill assistrespiration by which of the following mechanisms? A.Preventing bronchial collapse and air trapping in the lungsduringexhalation B. Increasing the res
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