a nurse is caring for a client who's receiving mechanical ventilation when the low-
pressure alarm sounds. which of the following situations should the nurse recognize as
a possible cause of the alarm?
A.) Excess secretions
B.) Kinks in the tubing
C.) Artificial airway cuff leak
D.) Biting on the endotracheal tube - artificial airway cuff leak
rationale:
An artificial airway cuff leak interferes with oxygenation and causes the low-pressure
alarm to sound.
a nurse is providing discharge teaching to a client who has a temporary tracheostomy.
which of the following statements by the client indicates an understanding of the
teaching?
A.) "Ringing in the ears is an adverse effect of this medication."
B.) "Have your skin test repeated in 4 months to show a positive result."
C.) "Expect your urine and other secretions to be orange while taking this medication."
D.) "Remember to take this medication with a sip of water just before your first bite of
each meal." - "I should remove the old twill ties after the new ties are in place."
, rationale:
As a safety measure, the nurse should teach the client to wait until the new ties are in
place to remove the old ties. This practice can prevent accidental decannulation.
a nurse is caring for 4 clients. which of the following clients is at greatest risk for a
pulmonary embolism?
A.) A client who is 48 hr postoperative following a total hip arthroplasty
B.) A client who is 8 hr postoperative following an open surgical appendectomy
C.) A client who is 2 hr postoperative following an open reduction external fixation of the
right radius
D.) A client who is 4 hr postoperative following a laparoscopic cholecystectomy - A
client who is 48 hr postoperative following a total hip arthroplasty
rationale:
The nurse should identify that a client who has undergone a total hip arthroplasty
surgery is at greatest risk for a pulmonary embolus because of decreased mobility of
the affected extremity and an increased amount of blood clots forming in the veins of
the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72
hr following the arthroplasty. The nurse should intervene to reduce the risk by applying
sequential compression devices or antiembolic stockings and by administering
anticoagulant medications.
a nurse is caring for a newly admitted client who has emphysema. the nurse should
place the client in which of the following positions to promote effective breathing?
A.) Lateral position with a pillow at the back and over the chest to support the arm
B.) High-Fowler's position with the arms supported on the overbed table
C.) Semi-Fowler's position with pillows supporting both arms
D.) Supine position with the head of the bed elevated to 15° - High-Fowler's position
with the arms supported on the overbed table
rationale:
The nurse should place the client in a position that allows for greater expansion of the
chest, such as sitting upright and leaning slightly forward while supporting both arms
with pillows for comfort on the overbed table.
a nurse is caring for a client who has asthma and is receiving albuterol. for which of the
following adverse effects should the nurse monitor the client?
pressure alarm sounds. which of the following situations should the nurse recognize as
a possible cause of the alarm?
A.) Excess secretions
B.) Kinks in the tubing
C.) Artificial airway cuff leak
D.) Biting on the endotracheal tube - artificial airway cuff leak
rationale:
An artificial airway cuff leak interferes with oxygenation and causes the low-pressure
alarm to sound.
a nurse is providing discharge teaching to a client who has a temporary tracheostomy.
which of the following statements by the client indicates an understanding of the
teaching?
A.) "Ringing in the ears is an adverse effect of this medication."
B.) "Have your skin test repeated in 4 months to show a positive result."
C.) "Expect your urine and other secretions to be orange while taking this medication."
D.) "Remember to take this medication with a sip of water just before your first bite of
each meal." - "I should remove the old twill ties after the new ties are in place."
, rationale:
As a safety measure, the nurse should teach the client to wait until the new ties are in
place to remove the old ties. This practice can prevent accidental decannulation.
a nurse is caring for 4 clients. which of the following clients is at greatest risk for a
pulmonary embolism?
A.) A client who is 48 hr postoperative following a total hip arthroplasty
B.) A client who is 8 hr postoperative following an open surgical appendectomy
C.) A client who is 2 hr postoperative following an open reduction external fixation of the
right radius
D.) A client who is 4 hr postoperative following a laparoscopic cholecystectomy - A
client who is 48 hr postoperative following a total hip arthroplasty
rationale:
The nurse should identify that a client who has undergone a total hip arthroplasty
surgery is at greatest risk for a pulmonary embolus because of decreased mobility of
the affected extremity and an increased amount of blood clots forming in the veins of
the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72
hr following the arthroplasty. The nurse should intervene to reduce the risk by applying
sequential compression devices or antiembolic stockings and by administering
anticoagulant medications.
a nurse is caring for a newly admitted client who has emphysema. the nurse should
place the client in which of the following positions to promote effective breathing?
A.) Lateral position with a pillow at the back and over the chest to support the arm
B.) High-Fowler's position with the arms supported on the overbed table
C.) Semi-Fowler's position with pillows supporting both arms
D.) Supine position with the head of the bed elevated to 15° - High-Fowler's position
with the arms supported on the overbed table
rationale:
The nurse should place the client in a position that allows for greater expansion of the
chest, such as sitting upright and leaning slightly forward while supporting both arms
with pillows for comfort on the overbed table.
a nurse is caring for a client who has asthma and is receiving albuterol. for which of the
following adverse effects should the nurse monitor the client?
