2024/2025 Fundamentals Adaptive Quiz Test 1 - Questions with Verified Answers

2024/2025 Fundamentals Adaptive Quiz Test 1 - Questions with Verified Answers Which assessment finding is considered the earliest sign of decreased tissue oxygenation? Unexplained restlessness Which physical assessment maneuver is the nurse performing when instructing the client to breathe in slowly and a little more deeply than normal through the mouth? Auscultation Which physical assessment findings of a client suspected of having a respiratory disorder would be considered normal? Select all that apply. Pink nasal mucosa, midline trachea, non labored breathing of 14/min What finding would be consistent with long-standing hypoxemia in a client who reports shortness of breath? Clubbing A client is admitted with a sudden onset of dyspnea and chest pain. What are the interventions in the order in which the nurse will perform them to provide comfort to the client? 1. Notifying the Rapid Response Team 2. Reassuring the client and family members 3. elevate the head of the bed to help the client breathe easier 4. Prepare oxygen therapy and blood gas analysis 5. Monitoring and assessing for other changes Which would the nurse consider to be a potential respiratory system-related complication of surgery? Atelectasis An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation? Teach coughing and deep-breathing exercises. The nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate. What should the nurse do immediately in this situation? Stop administering the medication A child who reports shortness of breath, wheezing, and coughing is found to have pulmonary edema and is prescribed furosemide. Which nursing interventions would be beneficial to the client? Select all that apply. Checking the child's weight every day Calculating the dose of drug as carefully as possible Assessing the child regularly to help prevent electrolyte loss Continuous high-pitched squeaking or musical sounds that result from rapid vibration of bronchial walls. They are associated with bronchospasms or airway obstruction Wheezing Creaking or grating sounds caused by roughened, inflamed pleural surfaces rubbing together. They are associated with pleurisy, pneumonia, or a pulmonary infarct. Pleural friction rubs Normal, low-pitched rustling sounds heard over peripheral lung fields Vesicular breath sounds Normal, harsh, hollow, tubular, blowing sounds heard over the trachea and larynx. Bronchial breath sounds What condition would a nurse suspect in a client with abnormal respirations with alternating periods of apnea and rapid breathing? Cheyne-Stokes respirations The normal RBC count for a healthy male 4.7-6.1 million A client is transferred to an acute care nursing unit after surgery. Which action of the nurse is most important and should be performed first? Assess the patency of airway. The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? A low hemoglobin level causes reduced oxygen-carrying capacity. A client receives a prescription for morphine via patient-controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first? Respirations While reviewing the medical reports in an acute care setting, the nurse finds that the client is at risk for kidney damage and requests the healthcare provider to increase the intravenous fluid rate as a priority nursing intervention. Which finding supports the nurse's conclusion? Urine output is 25mL/hr What is the priority nursing action for a client with delirium? creating a calm safe environment What should be the priority action of the nurse who is caring for a client with a leg in traction? Assessing skin integrity What is considered to be the highest priority for an assault victim who presents to the emergency department? Ensuring the client's emotional and physical safety The nurse is caring for a client with a platelet count of 50,000 cells per microliter. Which recommendation is inappropriate for the client? Shaving with a straight blade The nurse is caring for clients in the pulmonary unit and suspects that one has tuberculosis. What is the priority nursing intervention in this situation? Move patient into airborne isolation room The nurse is caring for a client with chronic pain who is on opioid treatment. The client has constipation, nausea, vomiting, level 3 sedation, respiratory rate of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as highest priority? Respiratory rate and sedation. Level 3 sedation needs immediate intervention The client is receiving high-flow intravenous (IV) fluid replacement therapy. Which nursing assessment findings are consistent with fluid volume overload? Bounding pulse, presence of dependent edema, and neck vein distention in the upright position The nurse is caring for a client who survived a severe burn injury. Which action should the nurse perform immediately based on priority? Assessing airway patency What are the priority nursing interventions for a client with neutropenia in an emergency department? Obtain blood cultures immediately, Administer antibiotics STAT as prescribed While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation? Stop the blood transfusion immediately. Which first line medication would the nurse state is used to treat anaphylactic reactions? Epinephrin Which nursing intervention for opening the airway should be performed in an unconscious client with a spinal injury? Performing a jaw thrust maneuver. The jaw thrust maneuver is the recommended procedure for opening the airway of an unconscious client with a possible spinal or neck injury. Needle thoracostomy should be performed in a client with absent breath sounds. Cardiopulmonary resuscitation should be initiated in a client when there is no pulse. Providing oxygen via a nonrebreather mask is mainly performed when the client is conscious. In what ways can a nurse prevent medication errors? Avoid using abbreviations and acronyms Minimize the use of verbal and telephone orders Check three times before giving a drug by comparing the drug order and medication profile Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do? -Assess the client's condition every hour. A restraint impedes the movement of a client; therefore a client's condition needs to be assessed every hour. All restraints are required to be prescribed every 24 hours. Restraints should be removed and activity and skin care provided at least every 2 hours to prevent contractures and skin breakdown. Output from tubes may be monitored hourly, but generally does not need to be documented as frequently as every 2 hours. Generally output from tubes is emptied, measured, and documented at the end of each shift. A client who is in critical condition or in the immediate postoperative period may have urinary output measured hourly because this reflects cardiovascular status A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report? A listing of facts related to the incident as witnessed by the nurse A primary healthcare provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this prescription? Recognizing that PRN prescriptions for restraints are unacceptable A client with multiple injuries from a motor vehicle accident now is permitted out of bed to a chair but is not permitted to bear weight on the lower extremities. When using a mechanical lift to transfer the client, it is essential that the nurse do what? Fold the client's arms across the chest