NURSING 1429 Prep U Week 4 Quiz Questions & Answers Graded A+

NURSING 1429 Prep U Week 4 Quiz Questions & Answers 1. A client with carbon monoxide poisoning is treated in the emergency department of an acute care facility. Which clinical manifestations should the nurse expect in this client? Select all that apply. dizziness pulse oximetry of 99% on room air headache nausea and vomiting 2. A client arrives to the emergency department (ED), with reports of chest pain. Electrocardiograph (ECG) exhibits an elevated ST segment. What are the priority actions by the nurse? Select all that apply. improving myocardial oxygenation relieving pain reduce cardiac output 3. A nurse is caring for a client after a lung biopsy. Which assessment findings would be anticipated? Select all that apply. respiratory rate of 28 breaths/minute oxygen saturation level of 94% on 3 L of oxygen client stating pain level of 4 out of 10 that decreases with pain medication client dozing when left alone but awakening easily pink tinged sputum expectorated with coughing 4. The nurse is caring for a client who has sickle cell disease (SCD). The client is reporting pain in the back, chest, and extremities. The nurse anticipates that the client may present with what other clinical manifestation(s)? Select all that apply. nausea hypertension tachypnea swelling 5. A neonate has been placed on cardiac and apnea monitoring in the neonatal nursery. The nurse notes that the apnea alarm repeatedly triggers. Place the following actions in the order they would be completed by the nurse. All options must be used. Perform a focused assessment on the neonate. Count the respiratory rate for 60 seconds. Silence the alarm to decrease environmental stimuli. Check all connections on the apnea monitor. Document the assessment findings, interventions, and neonate’s response. 6. The nurse working in a critical care unit is a caring for a client that experiences respiratory arrest. In what order will the nurse respond? All options must be used. Call for emergency help. Begin emergency resuscitation. Document the resuscitation. Complete an incident report. Alert the family to the event. Restock the room with emergency equipment. 7. A client was admitted to the emergency department (ED) following a workplace accident and has just experienced brainstem death. The nurse recognizes that the client is likely an appropriate donor for tissue and organs. What actions related to organ donation should the (ED) nurse perform? Ensure that the family has a quiet, private place to discuss their decision around tissue donation. Support and validate the decision that the client's family makes. 8. The unlicensed assistive personnel (UAP) reports to the registered nurse that a client admitted with pneumonia is very diaphoretic. The nurse reviews the following vital signs in the medical record obtained by the UAP. What should the nurse do? Select all that apply. Check the urine output. Ask the client to drink more fluids. Notify the health care provider (HCP). Administer acetaminophen as prescribed. 9. A nurse, on the pediatric unit, received shift handoff on a 15-month-old with the following needs. Using Maslow’s hierarchy framework, prioritize the following nursing care activities for the toddler. All options must be used. clearing the airway of thick secretions notifying the health care provider about suspected compartment syndrome changing a soiled diaper administering antipyretics for an axillary temperature of 103°F (39.4°C) progressing the diet after surgery 10. The nurse is teaching a client how to use a metered-dose inhaler. Place the steps for using a metered-dose inhaler in order. All options must be used. Remove cap and hold the inhaler upright. Shake the inhaler. Tilt head back slightly and breathe out slowly all the way. Open mouth and position inhaler 1 to 2 in (2.5 to 5 cm) away from mouth. Press the button on the inhaler while breathing in. Breathe in slowly and deeply for as long as possible. 11. The nurse is caring for a pediatric client that is having an allergic reaction to food. Place the nursing actions for providing care to this client in chronological order. All options must be used. Assess respiratory effort. Administer a histamine blocker. Ask the family what foods the child is allergic to. Document the reaction. Provide teaching about medications. 12. A client on mechanical ventilation continues to be hypoxic following therapy with positive end- expiratory pressure (PEEP). The nurse prioritizes what intervention to reduce oxygen demand? Administer neuromuscular blockers. 13. The nurse is caring for a 7-year-old client with asthma on a pediatric medical unit. What aspect of the client's medical history alerts the nurse to a higher risk for an acute, severe asthma exacerbation? recently prescribed an oral corticosteroid 14. A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? assessing the client's respiratory status, orientation, and skin color 15. A client with acute respiratory distress syndrome is showing signs of increased dyspnea. The nurse reviews a report of blood gas values (see report). Which finding is abnormal? PaCO2 16. A client has a dull headache, is dizzy, and has an increased pulse rate. The results of arterial blood gas analysis are as follows: pH 7.26; partial pressure of carbon dioxide, 50 mm Hg (6.7 kPa); and bicarbonate, 24 mEq/L (24 mmol/L). These findings indicate which acid-base imbalance? respiratory acidosis 17. A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows to monitor closely for complications that include which of the following? acute respiratory distress syndrome (ARDS) 18. Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel and a compound fracture of the right tibia and fibula and multiple lacerations and contusions. What is the priority nursing goal for this client? Maintain adequate oxygenation. 19. A nurse is caring for a client following an elective bronchoscopy. Which intervention by the nurse is most appropriate? Do not give the client anything by mouth until the gag reflex returns. 20. A nurse is assigned to triage the care of four clients. Which client should the nurse assess first? client with a sore throat who now has a muffled voice and is drooling 21. A nurse is caring for a client with tuberculosis. Which infection-control technique is the priority when caring for this client? wearing an N95 respirator when caring for the client 22. A nurse is planning postoperative care for a client who has received a general anesthetic. During the immediate postoperative period, which nursing assessment should the nurse be most concerned about? heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24 23. A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first? Maintain adequate oxygenation. 24. A nurse is caring for a client who recently underwent a tracheostomy. What is the nurse's first priority when caring for this client? suctioning to keep the airway patent 25. At 2300, a client is admitted to the emergency department with a respiratory rate of 44 breaths/minute and audible wheezes. Oxygen and methylprednisolone IV are administered. At 2330, the client's oxygen saturation is 86%, with wheezing present. Which medication will the nurse plan to administer next? albuterol (salbutamol) nebulizer 26. A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3–), 24 mEq/L. Based on these values, the nurse suspects You Selected: respiratory alkalosis. Correct response: respiratory alkalosis. Explanation: Remediation: Add a Note Question 27 See full question 1m Report this Question A client is brought to the emergency department following an automobile accident. Physical assessment reveals tachycardia, dyspnea, and absent breath sounds over the right lung. Which action is the nurse's most appropriate action? You Selected: preparing the client for a chest tube insertion Correct response: preparing the client for a chest tube insertion Explanation: Remediation: Add a Note Question 28 See full question 49s Report this Question Which is a priority goal for the client with chronic obstructive pulmonary disease (COPD)? You Selected: maintaining functional ability Correct response: maintaining functional ability Explanation: Remediation: Add a Note Question 29 See full question 56s Report this Question A client has a central venous catheter inserted into the subclavian vein. The nurse assesses the client immediately following the insertion of the catheter and notes a sudden onset of chest pain and shortness of breath. Which complication should the nurse be prepared to treat? You Selected: pneumothorax Correct response: pneumothorax Explanation: Remediation: Add a Note Question 30 See full question 1m 37s Report this Question A nurse is caring for a client with influenza who becomes agitated and restless. Which nursing action is the priority? You Selected: Assess the client’s lungs and check the oxygen saturation. Correct response: Assess the client’s lungs and check the oxygen saturation. Explanation: Add a Note Question 31 See full question 25s Report this Question While reviewing the arterial blood gas values of a client with emphysema, the nurse should identify which PaCO2 values as indicating the need for immediate intervention? You Selected: 80 mm Hg Correct response: 80 mm Hg Explanation: Remediation: Add a Note Question 32 See full question 1m 36s Report this Question Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration? You Selected: The client’s respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing. Correct response: The client’s respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing. Explanation: Remediation: Add a Note Question 33 See full question 1m 18s Report this Question A nurse is assisting a client with a chronic respiratory disease to walk in the hallway. The nurse observes as the client’s SpO2 drops from 94% to 88% during ambulation. Which iaction of the nurse is appropriate? You Selected: Administer low flow supplemental O2. Correct response: Administer low flow supplemental O2. Explanation: Add a Note Question 34 See full question 40s Report this Question When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. How should the nurse should record the breathing pattern? You Selected: Cheyne-Stokes respiration Correct response: Cheyne-Stokes respiration Explanation: Remediation: Add a Note Question 35 See full question 41s Report this Question A client with emphysema is at a greater risk for developing what acid–base imbalance? You Selected: chronic respiratory acidosis Correct response: chronic respiratory acidosis Explanation: Remediation: Add a Note Question 36 See full question 55s Report this Question The nurse observes that a client admitted with asthma is anxious, has audible wheezing, and is using the neck muscles when breathing. What actions would be appropriate? You Selected: Position in high Fowler’s position and administer an albuterol sulfate inhaler. Correct response: Position in high Fowler’s position and administer an albuterol sulfate inhaler. Explanation: Remediation: Add a Note Question 37 See full question 48s Report this Question A nurse is assessing a client using a tracheostomy tube. The client has bilateral rhonchi in the upper lobes of the lungs and is unsuccessful in coughing up secretions. Which action should the nurse take? You Selected: Use a sterile suction kit to suction the client. Correct response: Use a sterile suction kit to suction the client. Explanation: Add a Note Question 38 See full question 1m 12s Report this Question A client who is intubated on mechanical ventilation develops subcutaneous emphysema. Which ventilator setting should the nurse anticipate being adjusted for this client? You Selected: positive end-expiratory pressure (PEEP) Correct response: positive end-expiratory pressure (PEEP) Explanation: Remediation: Add a Note Question 39 See full question 1m 44s Report this Question The nurse has received lab reports for several clients undergoing care. Which set of arterial blood gas (ABG) results will the nurse investigate first? You Selected: pH 7.34, partial pressure of arterial carbon dioxide (PaCO2) 36 mmHg, partial pressure of arterial oxygen (PaO2) 95 mmHg, bicarbonate (HCO3–) 20 mEq/L Correct response: pH 7.49, PaCO2 30 mmHg, PaO2 75 mmHg, and HCO3– 22 mEq/L Explanation: Remediation: Add a Note Question 40 See full question 39s Report this Question A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? You Selected: light-headedness or paresthesia Correct response: light-headedness or paresthesia Explanation: Remediation: Add a Note Question 41 See full question 35s Report this Question The nurse is caring for a client that is experiencing increasing shortness of breath. The client is pale and slight circumoral cyanosis is developing. Which laboratory test best measures the adequacy of tissue oxygenation? You Selected: arterial blood gases Correct response: arterial blood gases Explanation: Add a Note Question 42 See full question 1m 3s Report this Question A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which result is consistent with this disorder? You Selected: pH 7.28, PaO2 50 mm Hg Correct response: pH 7.28, PaO2 50 mm Hg Explanation: Remediation: Add a Note Question 43 See full question 52s Report this Question An adolescent with cystic fibrosis has been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which initial nursing actions are most important? You Selected: applying an oximeter and initiating respiratory therapy Correct response: applying an oximeter and initiating respiratory therapy Explanation: Remediation: Add a Note Question 44 See full question 31s Report this Question A nurse administers albuterol, as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? You Selected: Respiratory rate of 22 breaths/minute Correct response: Respiratory rate of 22 breaths/minute Explanation: Remediation: Add a Note Question 45 See full question 41s Report this Question A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of: You Selected: respiratory alkalosis. Correct response: respiratory alkalosis. Explanation: Remediation: Add a Note Question 46 See full question 29s Report this Question The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The decrease in pH exists because the client's lungs: You Selected: are unable to blow off carbon dioxide. Correct response: are unable to blow off carbon dioxide. Explanation: Remediation: Add a Note Question 47 See full question 1m 17s Report this Question A client has undergone a left hemicolectomy for bowel cancer. Which combination of activities is most effective in preventing the occurrence of postoperative pneumonia in this client? You Selected: coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Correct response: coughing, breathing deeply, frequent repositioning, and using an incentive spirometer Explanation: Remediation: Add a Note Question 48 See full question 19s Report this Question A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan? You Selected: Encourage the client's communication, allowing time to select or write words. Correct response: Encourage the client's communication, allowing time to select or write words. Explanation: Remediation: