Download PN2 NUR2571 exam 1 questions Already graded A and more Exams Nursing in PDF only on Docsity! 1 4. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? b. Measure and compare cuff pressures. ANS: B 2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? c. Client has reduced breath sounds. Nurse calls physician immediately. ANS: C 3. A nurse assesses a clients respiratory status. Which information is of highest priority for the nurse to obtain? d. Occupation and hobbies ANS: D 2. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first? a. Cardiac rate and rhythm ANS: A 6. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next? a. Assess clients rate, rhythm, and depth of respiration. 7. A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action? b. Absent breath sounds ANS: B 8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first? a. Apply oxygen by mask or nasal cannula. 2 8. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure? d. Validate that informed consent has been given by the client. ANS: D 5 ANS: C 14.A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain? b. Place warm compresses on the site. ANS: B 17.A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below should the nurse use to draw up and administer the heparin? ANS: D (10-mL syringe picture) 2.A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.) a. Phlebitis c. Thrombophlebitis ANS: A, C 11. While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? a. Contact the provider and prepare for intubation. ANS: A 8.A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next? 6 d. Stop the infusion of intravenous fluids. 3. A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor d. Ecchymosis behind the ear ANS: A, D 7 12. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive? b. Sodium bicarbonate 100 mEq diluted in 1 L of D5W 5. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? c. A 55-year-old woman who is 50 pounds overweight ANS: C 7. A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first? a. Initiate Standard Precautions. ANS: A 2.A client is prescribed 250 mL of normal saline to infuse over 4 hours via gravity. The facility supplies gravity tubing with a drip factor of 15 drops/mL. At what rate (drops/min) should the nurse set the infusion to ANS: 16 drops/min 1.A client is prescribed 1000 mL of normal saline to infuse over 24 hours. At what rate should the nurse set the pump (mL/hr) to deliver this infusion? (Record your answer using a whole number.) mL/hr ANS:42--1000 mL 24 hours = 41.6 mL/hr. (42 is the answer) 12. A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, How will this medication help me? How should the nurse respond? c. This medication will promote daytime wakefulness. ANS: C 2. A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.) 10 c. Sudden onset of shortness of breath ANS: B, C 8. A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met? b. Intact skin behind the ears 11 10. A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next? c. Assess the clients gag reflex before giving any food or water. 8.A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen ANS: A 12.A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? c. I will take this medication on an empty stomach. ANS: C 3. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the clients oxygen saturation. ANS: A 15.A client has been hospitalized with tuberculosis (TB). The clients spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. ANS: A 16.A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? 12 d. Visiting Nurses for directly observed therapy ANS: D 15 a. Lets discuss potential factors that increase your symptoms. ANS: A 10. A nurse cares for a client who is prescribed mesalamine (Asacol) for ulcerative colitis. The client states, I am having trouble swallowing this pill. Which action should the nurse take? c. Ask the health care provider to prescribe the medication as an enema instead. ANS: C 7. A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) a. Lower gastrointestinal bleeding Erosion of the bowel wall b. Abscess formation Localized pockets of infection develop in the ulcerated bowel lining d. Nonmechanical bowel obstruction Paralysis of colon resulting from colorectal cancer ANS: A, B, D 1. The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of the following? (Select all that apply.) a. Alcohol b. Caffeine c. Corticosteroids e. Nonsteroidal anti-inflammatory drugs (NSAIDs) ANS: A, B, C, E 13. A client is recovering from an esophagogastroduodenoscopy (EGD) and requests something to drink. What action by the nurse is best? b. Assess the clients gag reflex. ANS: B 19. A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? c. Add vegetables such as broccoli and cauliflower to your new diet. ANS: C 16 1. A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins e. Skeletal muscle weakness ANS: A, B, E 17 15.A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client? d. Infection ANS: D 4. A nurse has conducted a community screening event for oral cancer. What client is the highest priority for referral to a dentist? b. Client who smokes and drinks daily ANS: B 6. A client is having a temporary tracheostomy placed during surgery for oral cancer. What action by the nurse is best to relieve anxiety? a. Agree on a postoperative communication method. ANS: A 9. A client had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is the priority? c. Place the client in a high-Fowlers position. ANS: C 2. A nurse studying cancer knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.) a. Coal miner c. Metal worker d. Plumber e. Textile worker ANS: A, C, D, E 8.A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up into the lower part of the clients neck. What action by the nurse takes priority? 20 1. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism? a. Increased rate and depth of respirations 13. A nurse is assessing a client with hypokalemia, and notes that the clients handgrip 21 strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first? a. Assess the clients respiratory rate, rhythm, and depth. ANS: A 6. After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all that apply.) c. Strong productive cough d. Active bowel sounds ANS: C, D 7. A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.) b. Use a draw sheet to reposition the client in bed. d. Provide nonslip footwear for the client to use when out of bed. ANS: B, D 3. A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy? d. Metabolic alkalosis ANS: D 4. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take? d. Teach the client fall prevention measures. ANS: D 9. A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority? b. Notify the provider immediately. ANS: B 10. A nurse assesses a clients oral cavity and observes the condition depicted in the photo below: What action by the nurse is best? 22 b. Assess the client for dysphagia. ANS: B 14. A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? d. Assess the clients bowel sounds. ANS: D 25 c. I take sodium bicarbonate after every meal to prevent heartburn. ANS: C 13. A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next? b. Notify the Rapid Response Team. ANS: B 13. The nurse assesses the client using the device pictured below to deliver 50% O2: The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? c. Immediately increase the flow rate. ANS: C 3. A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first? d. Ask the client if he or she has ever been evaluated for sleep apnea. ANS: D 1. A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? d. A 27-year-old client with a heart rate of 120 beats/min ANS: D 28. A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Which action should the nurse take first? d. Initiate oxygenation therapy to increase saturation to 92%. ANS: D 5.The charge nurse on a medical unit is preparing to admit several clients who have possible pandemic flu during a preparedness drill. What action by the nurse is best? b. Cohort the clients in the same area of the unit. 26 c. Inquire as to recent travel outside the United States ANS: B and or C 13.A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately? 27 b. Alanine aminotransferase (ALT): 180 U/L ANS: B 18.A client has the diagnosis of valley fever accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on? d. Oral fluconazole (Diflucan) ANS: D 7. A nurse is caring for four clients. After receiving the hand-off report, which client should the nurse see first? b. Client who had a tracheostomy 4 hours ago and needs frequent suctioning ANS: B 4.A client with an esophageal tumor has difficulty swallowing and has been working with a speech-language pathologist. What assessment finding by the nurse indicates that the priority goal for this problem is being met? b. Lungs clear after meals and snacks ANS: B 13.A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first? c. Client who had an esophagectomy with a respiratory rate of 32/min ANS: C 11. A nurse cares for a client who states, My husband is repulsed by my colostomy and refuses to be intimate with me. How should the nurse respond? a. Lets talk to the ostomy nurse to help you and your husband work through this. ANS: A 30 ANS: A, B, D, E 1. The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.) 31 a. Delayed gastric emptying b. Eating large meals c. Hiatal hernia d. Obesity ANS: A, B, C, D 21.A nurse admits a client from the emergency department. Client data are listed below: History/70 years of age/ History of diabetes/ On insulin twice a day/ Reports new-onset dyspnea and productive cough/ What action by the nurse is the priority? a. Administer oxygen at 4 liters per nasal cannula. 3. A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The clients blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate? c. Start a large-bore IV with normal saline. 12. A nurse assesses a client with Crohns disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen 13. A nurse reviews the chart of a client who has Crohns disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L 32 19. A nurse plans care for a client with Crohns disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this clients plan of care? b. Skin protection