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NURSING NCLEX Module 9 Exam Questions and Answers,100% CORRECT

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NURSING NCLEX Module 9 Exam Questions and Answers 1. 1.ID: 9477047208 A client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give way” in the abdo... minal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action? A. Document the findings B. Contact the health care provider C. Place the client in a supine position with the legs flat D. Cover the abdominal wound with a sterile dressing moistened with sterile saline solution Correct 1. Rationale: Wound dehisQuestions 1. 1.ID: 9477047208 A client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give way” in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action? A. Document the findings B. Contact the health care provider C. Place the client in a supine position with the legs flat D. Cover the abdominal wound with a sterile dressing moistened with sterile saline solution Correct Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9477054249 A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright­red blood. The nurse should take which immediate action? A. Notify the surgeon Correct B. Continue the assessment C. Check the client’s blood pressure D. Obtain a flashlight, gauze, and a curved hemostat Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 9477051455 A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action? A. Preparing the client for a perfusion scan B. Attaching the client to a cardiac monitor C. Administering oxygen by way of nasal cannula Correct D. Ensuring that the intravenous (IV) line is patent Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9477051498 A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply). A. Clamp the chest tube B. Chang the drainage system C. Assess the system for an external air leak Correct D. Reduce the degree of suction being applied E. Document assessment findings, actions taken, and client response Correct because an air leak may be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect. Additionally, a chest tube is not clamped unless this has been specifically prescribed in the agency’s policies and procedures. Changing the drainage system will not alleviate the problem. Reducing the degree of suction being applied will not affect the bubbling in the water seal chamber and could be harmful. The nurse would document the assessment findings and interventions taken in the client’s medical record. Test­Taking Strategy: Focus on the data in the question, noting that there is bubbling in the water seal chamber. Use knowledge regarding the priority actions in the care of a closed chest tube drainage system. Recalling that this may indicate an air leak will direct you to the correct options. Review the nursing actions to be taken immediately in the event that complications of a closed chest tube drainage system occur Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situation/Management Giddens Concepts: Care Coordination, Gas Exchange HESI Concepts: Nursing Interventions, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., p. 546). St. Louis: Mosby. Awarded 2.0 points out of 2.0 possible points. 5. 5.ID: 9477055619 A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action? A. Reinsert the chest tube B. Contact the health care provider C. Transfer the client back to bed D. Cover the insertion site with a sterile occlusive dressing Correct Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9477047967 A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first? A. Continue suctioning to remove the blood B. Check the degree of suction being applied Correct C. Encourage the client to cough out the bloody secretions D. Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 9477054269 A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client’s trachea but is unable to do so. Which action should the nurse take first? A. Call a code B. Contact the health care provider C. Administer a bronchodilator D. Disconnect the suction source from the catheter Correct Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 9477044479 A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which action should the nurse take first? A. Contact the health care provider B. Check for kinks in the drainage system Correct C. Check the client’s blood pressure and heart rate D. Connect a new drainage system to the client’s chest tube Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: 9477047216 A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take which action first? A. Call the health care provider B. Increase the rate of the IV infusion C. Check the client’s overall intake and output record Correct D. Administer a 250­mL bolus of normal saline solution (0.9%) Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 9477054279 A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? A. Check the client’s blood pressure B. Check the oxygen saturation level C. Have the client take some deep breaths D. Lower the head of the bed slowly until the dizziness is relieved Correct Awarded 1.0 points out of 1.0 possible points. 11. 11.ID: 9477047901 A nurse is preparing for intershift report when an unlicensed assistive personnel (UAP) pulls an emergency call light in a client’s room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client’s blood pressure is 88/60 mm Hg. Which action should the nurse take first? A. Call the health care provider B. Check the hourly urine output C. Check the IV site for infiltration D. Place the client in a modified Trendelenburg position Correct Awarded 1.0 points out of 1.0 possible points. 12. 12.ID: 9477052857 A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assess first? A. The client’s vital signs B. The amount of drainage C. The client’s lung sounds D. The chest tube connections Correct Awarded 1.0 points out of 1.0 possible points. 13. 13.ID: 9477055641 A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing? A. Steak B. Veal C. Cheese D. Oranges Correct Awarded 1.0 points out of 1.0 possible points. 14. 14.ID: 9477054227 A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The health care provider has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client’s room before allowing the client to drink? A. Straw B. Napkin C. Suction equipment Correct D. Oxygen saturation monitor Awarded 1.0 points out of 1.0 possible points. 15. 15.ID: 9477052847 A client in the postanesthesia care unit has an as­needed prescription for ondansetron. Which occurrence would prompt the nurse to administer this medication to the client? A. Paralytic ileus B. Incisional pain C. Urine retention D. Nausea and vomiting Correct Awarded 1.0 points out of 1.0 possible points. 16. 16.ID: 9477050283 A nurse administers scopolamine as prescribed to a client. For which side effect of this medication does the nurse monitor the client? A. Pupil constriction B. Increased urine output C. Complaints of dry mouth Correct D. Complaints of feeling sweaty Awarded 1.0 points out of 1.0 possible points. 17. 17.ID: 9477047248 A nurse is preparing a client for transfer to the operating room. Which action should the take in the care of this client at this time? A. Ensuring that the client has voided Correct B. Administering all daily medications C. Practicing postoperative breathing exercises D. Verifying that the client has not eaten for the last 24 hours Awarded 1.0 points out of 1.0 possible points. 18. 18.ID: 9477045874 A nurse receives a telephone call from a nurse on the post­anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client? A. Assess the patency of the airway Correct B. Check tubes and drains for patency C. Check the dressing for bleeding D. Assess the vital signs to compare them with preoperative measurements Awarded 1.0 points out of 1.0 possible points. 19. 19.ID: 9477045891 A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above which value? A. 85% B. 89% C. 95% Correct D. 100% Awarded 1.0 points out of 1.0 possible points. 20. 20.ID: 9477052876 A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon’s office? Select all that apply. A. Hematocrit 30% (0.30) B. Sodium 141 mEq/L (141 mmol/L) C. Hemoglobin 8.9 g/dL (89 g/L) D. Platelets 210× 103/μL (210 × 109/L) E. Serum creatinine 0.8 mg/dL (70 μmol/L) Awarded 2.0 points out of 2.0 possible points. 21. 21.ID: 9477052865 A client has been scheduled for magnetic resonance imaging (MRI). For which condition, a contraindication to MRI, does the nurse check the client’s medical history? A. Pancreatitis B. Pacemaker insertion Correct C. Type 1 diabetes mellitus D. Chronic airway limitation Awarded 1.0 points out of 1.0 possible points. 22. 22.ID: 9477047238 A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure? A. Flat Correct B. Semi­Fowler C. Side­lying, with the head of the bed elevated D. Sitting up in a recliner with the feet elevated Awarded 1.0 points out of 1.0 possible points. 23. 23.ID: 9477051477 A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which action should the nurse plan to take as part of routine after­care for this client? A. Administering a laxative B. Encouraging fluid intake Correct C. Maintaining the client on strict bed rest D. Holding all medications for at least 2 hours Awarded 1.0 points out of 1.0 possible points. 24. 24.ID: 9477043192 A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test? A. “I didn’t shampoo my hair.” Correct B. “I ate breakfast this morning.” C. “I didn’t take my anticonvulsant today.” D. “It was hard not to drink coffee this morning, but I knew that I couldn’t, so I didn’t.” Awarded 1.0 points out of 1.0 possible points. 25. 25.ID: 9477049148 Blood is drawn from a male client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level? A. 1.7 mg/dL (101.2 μmol/L) B. 4.4 mg/dL (262 μmol/L) Correct C. 8.9 mg/dL (529.9 μmol/L) D. 12.8 mg/dL (762.1 μmol/L) Awarded 1.0 points out of 1.0 possible points. 26. 26.ID: 9477051424 A nurse is providing post­procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should provide the client with which information? A. To resume full activity the next day B. Not to eat or drink anything until the next morning C. To keep the shoulder completely immobilized for the rest of the day D. To report to the health care provider the development of fever or redness and heat at the site Correct Awarded 1.0 points out of 1.0 possible points. 27. 27.ID: 9477044448 A client is tested for HIV with the use of an enzyme­linked immunosorbent assay (ELISA), and the test result is positive. The nurse should provide which information to the client about the test? A. HIV infection has been confirmed B. The client probably has an opportunistic infection C. The test will need to be confirmed with the use of a Western blot Correct D. A positive test is a normal result and does not mean that the client is infected with HIV Awarded 1.0 points out of 1.0 possible points. 28. 28.ID: 9477047259 A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells per cubic millimeter of blood. The nurse interprets this test result as indicating which? A. Improvement in the client B. The need for antiretroviral therapy Correct C. The need to discontinue antiretroviral therapy D. An effective response to the treatment for HIV Awarded 1.0 points out of 1.0 possible points. 29. 29.ID: 9477044498 A client has just undergone a renal biopsy. Which intervention should the nurse include in the post­ procedure plan of care? A. Restricting fluid intake for the first 24 hours B. Periodically testing the urine for occult blood Correct C. Avoiding the administration of opioid analgesics D. Having the client ambulate in the room and hall for short distances Awarded 1.0 points out of 1.0 possible points. 30. 30.ID: 9477050216 A nurse has a prescription to collect a 24­hour urine specimen from a client. Which measure should the nurse take during this procedure? A. Keeping the specimen at room temperature B. Saving the first urine specimen collected at the start time C. Discarding the last voided specimen at the end of the collection time D. Asking the client to void, discarding the specimen, and noting the start time Correct Awarded 1.0 points out of 1.0 possible points. 31. 31.ID: 9477047283 A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important? A. Administering a sedative B. Encouraging fluid intake C. Administering an oral preparation of radiopaque dye D. Questioning the client about allergies to iodine or shellfish Correct Awarded 1.0 points out of 1.0 possible points. 32. 32.ID: 9477044488 A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which finding should the nurse assess the client? A. Bleeding Correct B. Renal colic C. Infection at the site D. Increased temperature Awarded 1.0 points out of 1.0 possible points. 33. 33.ID: 9477049161 A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting which finding? A. Urine output of 40 mL/hr B. Blood pressure of 118/76 mm Hg C. Respiratory rate of 18 breaths/min D. Pallor and coolness of the right leg Correct Awarded 1.0 points out of 1.0 possible points. 34. 34.ID: 9477054237 A nurse reviews a client’s urinalysis report. Which finding does the nurse recognize as abnormal? A. pH of 6.0 B. An absence of protein C. The presence of ketones Correct D. Specific gravity of 1.018 Awarded 1.0 points out of 1.0 possible points. 35. 35.ID: 9477055631 A nurse provides information to a client who is scheduled for cardiac catheterization to rule out coronary occlusion. The nurse should provide which information to the client? A. The procedure is performed in the operating room B. It is necessary to lie quietly on a hard x­ray table for about 4 hours C. The room is bright and well lit, and it is best to keep the eyes closed D. The client may have feelings of warmth or flushing during the procedure Correct Awarded 1.0 points out of 1.0 possible points. 36. 36.ID: 9477051487 A client who has sustained a myocardial infarction is scheduled to have an echocardiogram. Which measure should the nurse take before the procedure? A. Imposing nothing­by­mouth (NPO) status for 4 hours B. Asking the client to sign an informed consent form C. Asking the client about a history of allergy to iodine or shellfish D. Telling the client that the procedure is painless and takes 30 to 60 minutes to complete Correct Awarded 1.0 points out of 1.0 possible points. 37. 37.ID: 9477052827 A nurse in a health care provider’s office has just made an appointment for a client to undergo an exercise stress test. The nurse, in providing pre­procedure teaching, should provide which information to the client? A. Wear sweatpants and a heavy sweatshirt B. Eat a small meal just before the procedure C. Wear comfortable rubber­soled shoes such as sneakers Correct D. Avoid consuming caffeine for 30 minutes before the procedure Awarded 1.0 points out of 1.0 possible points. 38. 38.ID: 9477047944 A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24­hour period. What steps should the nurse take to initiate this prescription? Select all that apply. A. Giving the client a device holder to wear around the waist B. Giving the client a diary in which to record activity and symptoms C. Telling the client to rest as much as possible during the next 24 hours D. Instructing the client to enclose the monitor in plastic wrap before taking a bath E. Telling the client that occasional slight shocks from the monitor will be felt but that they are harmless Incorrect Awarded 1.0 points out of 2.0 possible points. 39. 39.ID: 9477044432 A client has undergone pericardiocentesis to treat cardiac tamponade. For which signs should the nurse assess the client to determine whether the tamponade is recurring? A. Decreasing pulse B. Rising blood pressure C. Distant muffled heart sounds Correct D. Falling central venous pressure (CVP) Awarded 1.0 points out of 1.0 possible points. 40. 40.ID: 9477051443 A nurse is watching as an unlicensed assistive personnel (UAP) measure the blood pressure (BP) of a hypertensive client. Which actions on the part of the UAP would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply. A. Measuring the BP after the client has sat quietly for 5 minutes B. Having the client sit with the arm bared and supported at heart level C. Used a cuff with a rubber bladder that encircles at least 60% of the limb Correct D. Measuring the BP after the client reports that he just drank a cup of coffee Correct E. Allowing the client to talk as the blood pressure is being measured Correct Awarded 3.0 points out of 3.0 possible points. 41. 41.ID: 9477044422 A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply. A. Setting the suction pressure to 60 mm Hg Correct B. Applying suction throughout the procedure Correct C. Assessing breath sounds before suctioning D. Placing the client in a supine position before the procedure Correct E. Hyperoxygenating the client with 100% oxygen before suctioning Awarded 3.0 points out of 3.0 possible points. 42. 42.ID: 9477047996 Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse checks the health care provider’s prescriptions to ensure that the prescribed flow is not greater than which liter (L) per minute (min)? A. 1 L/min B. 3 L/min Correct C. 4 L/min D. 6 L/min Awarded 1.0 points out of 1.0 possible points. 43. 43.ID: 9477049138 A client who experienced the sudden onset of respiratory distress has been intubated with an endotracheal tube. After the tube is placed in the trachea, the nurse should take which immediate action? A. Tape the tube in place B. Send the client for a chest x­ray C. Note how far the tube has been inserted D. Auscultate both lungs for the presence of breath sounds Correct Awarded 1.0 points out of 1.0 possible points. 44. 44.ID: 9477054296 A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication of which? A. The tube is patent Correct B. There is probably a kink in the tubing C. Suction should be added to the system D. The client is retaining airway secretions Awarded 1.0 points out of 1.0 possible points. 45. 45.ID: 9477045845 A nurse is performing nasotracheal suctioning on a client. Which observations should be cause for concern to the nurse? Select all that apply. A. The client becomes cyanotic. Correct B. Secretions are becoming bloody. Correct C. The client gags during the procedure. D. Clear to opaque secretions are removed. E. The heart rate varies from 80 to 82 beats/min. Awarded 2.0 points out of 2.0 possible points. 46. 46.ID: 9477044402 A nurse is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which coexisting problem is cause for the nurse to suspect that the oxygen saturation readings are not entirely accurate? A. Infection B. Hypertension C. Low blood pressure Correct D. Loss of cough reflex Awarded 1.0 points out of 1.0 possible points. 47. 47.ID: 9477047910 A nurse is reading the radiology report of a client with a chest tube attached to a closed drainage system who has undergone a chest x­ray. The report states that the client’s affected lung is fully reexpanded. The nurse anticipates that the assessment of the chest tube system will reveal which finding? A. No fluctuation in the water seal chamber Correct B. Continuous bubbling in the water seal chamber C. Increased drainage in the collection chamber D. Continuous gentle suction in the suction control chamber Awarded 1.0 points out of 1.0 possible points. 48. 48.ID: 9477050297 A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client? A. Assessing the client’s chest for crepitus once every 24 hours B. Taping the connections between the chest tube and the drainage system Correct C. Adding 20 mL of sterile water to the suction control chamber every shift D. Recording the volume of secretions in the drainage collection chamber every 24 hours Awarded 1.0 points out of 1.0 possible points. 49. 49.ID: 9477045827 A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse most concerned? A. Oxygen saturation of 97% B. Equal breath sounds in both lungs C. Absence of cough and gag reflexes Correct D. Respiratory rate of 20 breaths/min Awarded 1.0 points out of 1.0 possible points. 50. 50.ID: 9477051465 A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion through the right femoral vein. The nurse assesses for allergic reaction to the contrast medium by monitoring for the presence of which? A. Bradycardia B. Respiratory distress Correct C. Hematoma in the right groin D. Discomfort in the right groin Awarded 1.0 points out of 1.0 possible points. 51. 51.ID: 9477045862 A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the health care provider? Select all that apply. A. Unequal chest expansion Correct B. Pulse rate of 82 beats/min C. Respiratory rate of 22 breaths/min D. Diminished breath sounds in the right lung Correct E. Complaints of discomfort at the needle insertion site Awarded 2.0 points out of 2.0 possible points. 52. 52.ID: 9477050273 A nurse is monitoring a client who has undergone pleural biopsy. Which finding causes the nurse to suspect that the client is experiencing a complication? A. Warm, dry skin B. Mild pain at the biopsy site C. Complaints of shortness of breath Correct D. Capillary refill time of less than 3 seconds Awarded 1.0 points out of 1.0 possible points. 53. 53.ID: 9477050204 A client has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority? A. Ambulating the client B. Administering pain medication C. Encouraging copious fluid intake D. Checking for the return of the gag reflex Correct Awarded 1.0 points out of 1.0 possible points. 54. 54.ID: 9477044412 A client is receiving intermittent bolus feedings by way of a nasogastric tube. In which position should the nurse place the client once the feeding is complete? A. Supine B. Head of bed flat C. Left lateral position D. Head of bed elevated 30 to 45 degrees Correct Awarded 1.0 points out of 1.0 possible points. 55. 55.ID: 9477052837 A nurse has a prescription to discontinue a client’s nasogastric tube. The nurse auscultates the client’s bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath and do what? A. Exhale during tube removal B. Bear down during tube removal C. Hold the breath during tube removal Correct D. Breathe normally during tube removal Awarded 1.0 points out of 1.0 possible points. 56. 56.ID: 9477047274 A nurse checks the residual volume from a client’s nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client? A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed Correct B. Discard the residual volume properly and record it as output on the client’s fluid balance record C. Dilute the residual volume with water and inject it into the nasogastric tube, applying pressure on the plunger D. Mix the residual volume with the formula and pour it into the nasogastric tube, using a syringe without a plunger Awarded 1.0 points out of 1.0 possible points. 57. 57.ID: 9477045807 A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily? A. Placing the tube in warm water B. Hyperextending the head while inserting the tube C. Removing the tube if any resistance to insertion is met D. Asking the client to swallow as the tube is being advanced Correct Awarded 1.0 points out of 1.0 possible points. 58. 58.ID: 9477050235 A client who has undergone an esophagogastroduodenoscopy (EGD) returns from the endoscopy department. After checking the client’s gag reflex, which action should the nurse take? A. Taking the client’s vital signs Correct B. Giving the client a drink of water C. Monitoring the client for a sore throat D. Being alert to complaints of heartburn Awarded 1.0 points out of 1.0 possible points. 59. 59.ID: 9477044440 A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply. A. That informed consent is required Correct B. That the test takes about 4 hours to complete C. That no premedication for sedation will be necessary D. That food and fluids will be withheld before the procedure Correct E. That multiple position changes may be necessary to pass the tube Correct Rationale: The client must sign informed consent before the procedure, which takes about an hour to perform. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed. Food and fluids are withheld before the procedure to prevent aspiration. Multiple position changes may be necessary to facilitate the passage of the tube. Test­Taking Strategy: Focus on the subject, client preparation for an ERCP. Think about the procedure and how it is done. This will assist in eliminating the option that states that no premedication for sedation will be necessary and selecting the option that states multiple position changes may be necessary to pass the tube. Knowing that it is invasive will assist in selecting the option related to informed consent being required. Eliminate the option that states that test takes about 4 hours to complete because of the words "4 hours." Recalling that aspiration is a concern will assist in selecting the option that says to withhold food and fluids before the procedure. Review ERCP. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care: Diagnostic Tests Giddens Concepts: Client Education, Clinical Judgment HESI Concepts:Clinical Decision Making/Clinical Judgment, Teaching and Learning/Patient Education References: Ignatavicius, D., & Workman, M. (2013). Medical­surgical nursing: Patient­centered collaborative care. (7th ed., pp. 250, 252, 1188 ). St. Louis: Saunders. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., p. 881). St. Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 60. 60.ID: 9477052808 A client is scheduled for a barium swallow (esophagography) in 2 days. The nurse, providing preprocedure instructions, should tell the client to implement which measure? A. Eat a regular supper and breakfast B. Remove all metal and jewelry before the test Correct C. Expect diarrhea for a few days after the procedure D. Take all oral medications as scheduled with milk on the day of the test Awarded 1.0 points out of 1.0 possible points. 61. 61.ID: 9477050225 A nurse is preparing a client for colonoscopy. Into which position does the nurse assist the client for the procedure? A. Left Sims’ position Correct B. Lithotomy position C. Knee­chest position D. Right Sims’ position Awarded 1.0 points out of 1.0 possible points. 62. 62.ID: 9477047226 Polyethylene glycol–electrolyte solution is prescribed for a hospitalized client scheduled for colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate? A. Administering a cleansing enema. B. Calling the health care provider C. Documenting the diarrhea in the medical record Correct D. Giving intravenous replacement fluids in large amounts Awarded 1.0 points out of 1.0 possible points. 63. 63.ID: 9477047921 A health care provider is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client? A. Supine B. Upright Correct C. Left side–lying D. Right side–lying Awarded 1.0 points out of 1.0 possible points. 64. 64.ID: 9477054290 A nurse is reviewing the results of serum laboratory studies of a client with suspected hepatitis. Which increased parameter is interpreted by the nurse as the most specific indicator of this disease? A. Hemoglobin B. Serum bilirubin Correct C. Blood urea nitrogen (BUN) D. Erythrocyte sedimentation rate (ESR) Awarded 1.0 points out of 1.0 possible points. 65. 65.ID: 9477050290 A nurse is preparing to examine a client’s skin using a Wood light. What should the nurse do to facilitate this procedure? A. Darken the examining room Correct B. Administer a local anesthetic C. Obtain a signed informed consent D. Shave the skin and scrub it with povidone­iodine (Betadine) Awarded 1.0 points out of 1.0 possible points. 66. 66.ID: 9477049118 A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than which value? A. 7% Correct B. 9% C. 10% D. 15% Awarded 1.0 points out of 1.0 possible points. 67. 67.ID: 9477051407 A client with diabetes mellitus is scheduled to have blood drawn in the morning for a fasting blood glucose determination. What does the nurse tell the client that it is acceptable to consume on the morning of the test? A. Water Correct B. Tea without any sugar C. Coffee without any milk D. Clear liquids such as apple juice Awarded 1.0 points out of 1.0 possible points. 68. 68.ID: 9477047985 A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should provide the client with which information about the test? A. The test may be painful B. The test takes 2 to 3 hours C. Food and fluids are not allowed for 4 hours after the test D. Dye is injected and may cause a warm flushing sensation Correct Awarded 1.0 points out of 1.0 possible points. 69. 69.ID: 9477047292 A pelvic ultrasound is prescribed to evaluate a client’s ovarian mass. What should the nurse giving preprocedure instructions tell the client that it important to do before the procedure? A. Eat only a light breakfast B. Wear comfortable clothing and shoes C. Drink 6 to 8 glasses of water without voiding Correct D. Stop eating or drinking at midnight before the test Awarded 1.0 points out of 1.0 possible points. 70. 70.ID: 9477043178 A client has been given a diagnosis of multiple myeloma. Which result does the nurse reviewing the client’s laboratory findings recognize as being specifically related to this diagnosis? A. Increased calcium level Correct B. Decreased blood urea nitrogen (BUN) C. Increased white blood cell (WBC) count D. Decreased number of plasma cells in the bone marrow Awarded 1.0 points out of 1.0 possible points. 71. 71.ID: 9477050248 A woman has been scheduled for a routine mammogram. The nurse should provide the client with which information about the test? A. That mammography takes about 1 hour B. Not to eat or drink on the morning of the test C. That there is no discomfort associated with the procedure D. That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test Correct Awarded 1.0 points out of 1.0 possible points. 72. 72.ID: 9477049153 A client has made an appointment to for her annual Papanicolaou test (a.k.a. Pap smear). The nurse who schedules the appointment should provide which information to the client? A. Vaginal douching is required an hour before the test B. Spicy foods should not be eaten on the day of the test C. The test has absolutely no discomfort associated with it D. The test cannot be performed while the client is menstruating Correct Awarded 1.0 points out of 1.0 possible points. 73. 73.ID: 9477055681 A client who has just undergone a skin biopsy is listening to discharge instructions from the nurse. The nurse determines that the client needs further teachingif the client indicates that he plans to do what as part of aftercare? A. Use the antibiotic ointment as prescribed B. Return in 7 days to have the sutures removed C. Apply cool compresses to the site twice a day for 20 minutes Correct D. Call the health care provider if excessive drainage from the wound occurs Integrated Process: Teaching and Learning Content Area: Fundamentals of Care: Diagnostic Tests Giddens Concepts: Client Teaching, Clinical Judgment HESI Concepts: Clinical Decision Making/Clinical Judgment, Teaching and Learning/Patient Education Reference: Ignatavicius, D., & Workman, M. (2013). Medical­surgical nursing: Patient­centered collaborative care. (7th ed., p. 468). St. Louis: Saunders. @ Rationale: Cool compresses are not used on biopsy sites. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After dressing removal, the site is kept clean and dry but may be cleansed daily with tap water or saline solution. The health care provider may prescribe an antibiotic ointment to minimize local bacterial colonization, and the ointment should be used as directed. The nurse instructs the client to report any redness or excessive drainage at the site. Sutures are usually removed 7 to 10 days after biopsy. Test­Taking Strategy: Note the strategic words, needs further teaching. These words indicate a negative event query and the need to select the incorrect client statement. Recalling that the biopsy site should be kept dry will direct you to the correct option. Review aftercare instructions for skin biopsy. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care: Diagnostic Tests Giddens Concepts: Client Teaching, Clinical Judgment HESI Concepts: Clinical Decision Making/Clinical Judgment, Teaching and Learning/Patient Education Reference: Ignatavicius, D., & Workman, M. (2013). Medical­surgical nursing: Patient­centered collaborative care. (7th ed., p. 468). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 74. 74.ID: 9477049172 A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin. Which result indicates that the prescribed dose of phenytoin is therapeutic? A. 3 mcg/mL B. 8 mcg/mL C. 16 mcg/mL Correct D. 28 mcg/mL Awarded 1.0 points out of 1.0 possible points. 75. 75.ID: 9477044458 A client is receiving a continuous IV infusion of heparin for the treatment of deep vein thrombosis. The client’s activated partial thromboplastin time (aPTT) level is 88 seconds (88 seconds). The client’s baseline before the initiation of therapy was 30 seconds (30 seconds). Which action does the nurse anticipate is needed? A. Shutting off the heparin infusion B. Increasing the rate of the heparin infusion C. Decreasing the rate of the heparin infusion Correct D. Leaving the rate of the heparin infusion as is Incorrect Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., p. 627). St. Louis: Mosby. @ Rationale: The normal aPTT varies between 25 and 35 seconds (25 and 35 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is designed to keep the aPTT between 1.5 and 2.5 times normal. Therefore the client’s aPTT is somewhat increased but does not indicate a critical value. The infusion rate should be slowed and the aPTT rechecked as prescribed. A persistently increased aPTT indicates a risk for bleeding. Test­Taking Strategy: Focus on the data in the question. To answer this question accurately, it is necessary to be familiar with both the normal aPTT level and the therapeutic level needed after the institution of heparin therapy. Noting that the client’s baseline before the initiation of therapy was 30 seconds and recalling that the therapeutic dose for this client is intended to keep the aPTT between and 2.5 times normal will direct you to the correct option. Review the content related to heparin therapy. Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Pharmacology: Cardiovascular Medications Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision Making/Clinical Judgment, Evidence Based Practice/Evidence References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp. 568­570) St. Louis: Saunders. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., p. 627). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 76. 76.ID: 9477047975 A client with cardiovascular disease is scheduled to receive a daily dose of furosemide. Which potassium level would cause the nurse, reviewing the client’s electrolyte values, to contact the health care provider before administering the dose? A. 3.0 mEq/L (3.0 mmol/L) Correct B. 3.8 mEq/L (3.8 mmol/L) C. 4.2 mEq/L (4.2 mmol/L) D. 5.2 mEq/L (5.2 mmol/L) Awarded 1.0 points out of 1.0 possible points. 77. 77.ID: 9477045817 A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the total cholesterol level should be maintained at less than which value? A. 140 mg/dL (<3.64 mmol/L) Incorrect B. 200 mg/dL (<5.2 mmol/L) Correct C. 250 mg/dL (<6.5 mmol/L) D. 300 mg/dL (<7.8 mmol/L) Awarded 0.0 points out of 1.0 possible points. 78. 78.ID: 9477047268 A nurse is reviewing the results of renal function testing in a client with renal calculi. Which finding indicates to the nurse that the client’s blood urea nitrogen (BUN) level is within the normal range? A. 2 mg/dL (0.7 mmol/L) B. 18 mg/dL (6.3 mmol/L) Correct C. 25 mg/dL (8.75 mmol/L) D. 35 mg/dL (12.25 mmol/L) Awarded 1.0 points out of 1.0 possible points. 79. 79.ID: 9477049108 An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse who receives the report of the client’s laboratory work that the client’s hematocrit is normal? A. 10% ( 0.10) B. 22% ( 0.22) C. 30% ( 0.30) D. 43% ( 0.43) Correct Awarded 1.0 points out of 1.0 possible points. 80. 80.ID: 9477045837 A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for several serum laboratory tests. Which serum amylase value, noted by the nurse reviewing the results, would be expected in this client at this time? A. 48 units/L (0.816 μkat/L) B. 97 units/L (1.649 μkat/L) C. 150 units/L (2.55 μkat/L) D. 395 units/L (6.715 μkat/L) Correct Awarded 1.0 points out of 1.0 possible points. 81. 81.ID: 9477045883 A nurse is reviewing laboratory results for a client who is at risk for nephrotoxicity because of medications being taken. Which serum creatinine result does the nurse document as normal? A. 0.2 mg/dL (17.6 μmol/L) B. 1.0 mg/dL (88.3 μmol/L) Correct C. 2.8 mg/dL (247.3 μmol/L) D. 3.9 mg/dL (344.5 μmol/L) Awarded 1.0 points out of 1.0 possible points. 82. 82.ID: 9477050254 A client with type 1 diabetes mellitus has a blood glucose level of 620 mg/dL (34.4 mmol/L). After the nurse calls the health care provider to report the finding and monitors the client closely for which condition? A. Metabolic acidosis Correct B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis Awarded 1.0 points out of 1.0 possible points. 83. 83.ID: 9477050263 A nurse reviews the blood gas results of a client in respiratory distress. The pH is 7.32 and the PaCO2 is 50 mm Hg (6.65 kPa). Which acid­base imbalance does the nurse recognize in these findings? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis Correct D. Respiratory alkalosis Awarded 1.0 points out of 1.0 possible points. 84. 84.ID: 9477049195 Blood for arterial blood gas determinations is drawn on a client with pneumonia, and testing reveals a pH of 7.45, PaCO2 of 30 mm Hg (3.99 kPa)., and HCO3 of 19 mEq/L (19 mmol/L). The nurse interprets these results as indicative of which disorder? A. Compensated metabolic acidosis Incorrect B. Compensated respiratory alkalosis Correct C. Uncompensated metabolic alkalosis D. Uncompensated respiratory acidosis Rationale: The normal pH is 7.35 to 7.45. The normal PaCO2 is 35­45 mm Hg (4.66­5.98 kPa). The normal HCO3 (bicarbonate) is 22­26 mEq/L (22­26 mmol/L). In a respiratory condition, opposite effects will be seen in pH and PaCO2. In respiratory alkalosis, pH is increased and PaCO2 is decreased. Compensation occurs when the pH returns to within the normal range, even though either the carbon dioxide or bicarbonate (or both) is abnormal value. In a metabolic condition, pH and bicarbonate move in the same direction. Clients with pneumonia are at risk for respiratory alkalosis as a result of hypoxemia. Test­Taking Strategy: Focus on the subject, the acid­base disorder fro a client with pneumonia. Remember that in a respiratory imbalance you will find opposite responses between the pH and the PaCO2 as indicated in the question. Therefore uncompensated metabolic alkalosis and compensated metabolic acidosis are eliminated first. Next, remember that the pH is increased with alkalosis and compensation occurs, evidenced by a normal pH. The correct option reflects a respiratory alkalotic condition and compensation and involves the kind of blood gas values indicated in the question. Review the steps for interpreting blood gas values Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Fundamentals of Care: Acid­Base Giddens Concepts: Acid/Base, Clinical Judgment HESI Concepts: Acid/Base, Clinical Decision Making/Clinical Judgment References: Ignatavicius, D., & Workman, M. (2013). Medical­surgical nursing: Patient­centered collaborative care. (7th ed., pp. 207­208 ). St. Louis: Saunders. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., p. 304). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 85. 85.ID: 9477052887 A nurse is caring for a client who is vomiting. For which acid­base imbalance does the nurse assess the client? A. Metabolic acidosis B. Metabolic alkalosis Correct C. Respiratory acidosis D. Respiratory alkalosis Awarded 1.0 points out of 1.0 possible points. 86. 86.ID: 9477045899 A nurse is caring for a client with diarrhea. For which acid­base disorder does the nurse assess the client? A. Metabolic acidosis Correct B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis Awarded 1.0 points out of 1.0 possible points. 87. 87.ID: 9477055607 A client tells the nurse that he has been experiencing frequent heartburn and has been “living on antacids.” For which acid­base disturbance does the nurse recognize a risk? A. Metabolic acidosis B. Metabolic alkalosis Correct C. Respiratory acidosis D. Respiratory alkalosis Awarded 1.0 points out of 1.0 possible points. 88. 88.ID: 9477049184 A client has the following arterial blood gas (ABG) results: pH 7.51, PaCO231 mm Hg (4.12 kPa), PaO2 94 mm Hg (12.45 kPa), HCO3 24 mEq/L (24 mmol/L). Which acid­base disturbance does the nurse recognize in these results? A. Metabolic acidosis B. Metabolic alkalosis Incorrect C. Respiratory acidosis D. Respiratory alkalosis Correct Rationale: The normal pH is 7.35 to 7.45. The normal PaCO2 is 35­45 mm Hg (4.66­5.98 kPa). The normal HCO3 (bicarbonate) is 22­26 mEq/L (22­26 mmol/L). The normal PaO2 is 80­100 mm Hg (10.6­13.33 kPa). Acidosis is defined as a pH of less than 7.35; alkalosis is defined as a pH greater than 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PCO2. In respiratory alkalosis the pH is increased and the PCO2 is decreased. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L (22 mmol/L); metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L (26 mmol/L). This client’s ABG findings are consistent with respiratory alkalosis. Test­Taking Strategy: Focus on the subject, interpreting arterial blood gas values. Remember that in a respiratory imbalance you will find an opposite response between the pH and the PCO2, as indicated in the question. Therefore metabolic alkalosis and metabolic acidosis are eliminated first. Next remember that the pH is increased in alkalosis. This will direct you to the correct option. Review the steps involved in interpreting blood gas values. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Fundamentals of Care: Acid­Base Giddens Concepts: Acid/Base, Clinical Judgment HESI Concepts: Acid/Base, Clinical Decision Making/Clinical Judgment Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., p. 304). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 89. 89.ID: 9477047932 A client with histoplasmosis has the following arterial blood gas (ABG) results: pH 7.30, PaCO2 58 mm Hg (7.72 kPa), PaO2 75 mm Hg (9.93 kPa), HCO3 26 mEq/L (26 mmol/L). Which acid­base disturbance does the nurse recognize in these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis Correct D. Respiratory alkalosis Awarded 1.0 points out of 1.0 possible points. 90. 90.ID: 9477044470 A client is brought to the emergency department by a neighbor. The client is lethargic and has a fruity odor on the breath. The client’s arterial blood gas (ABG) results are pH 7.25, PaCO234 mm Hg (4.52 kPa), PaO2 86 mm Hg (11.3 kPa), HCO3 14 mEq/L (14 mmol/L). Which acid­base disturbance does the nurse recognize in these results? A. Metabolic acidosis Correct B. Metabolic alkalosis C. Respiratory acidosis Incorrect D. Respiratory alkalosis Awarded 0.0 points out of 1.0 possible points. 91. 91.ID: 9477047956 A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias Correct D. Dysrhythmias and decreased respiratory rate and depth Awarded 1.0 points out of 1.0 possible points. 92. 92.ID: 9477054259 A client with a history of lung disease is at risk for respiratory acidosis. For which signs and symptoms does the nurse assess this client? A. Disorientation and dyspnea Correct B. Drowsiness, headache, and tachypnea Incorrect C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth Awarded 0.0 points out of 1.0 possible points. 93. 93.ID: 9477055651 A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. For which signs and symptoms does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth Correct Awarded 1.0 points out of 1.0 possible points. 94. 94.ID: 9477051415 A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to promote which goal? A. Prevent the client from getting a nosebleed B. Give the client added fluid by way of the respiratory tree C. Humidify the oxygen that is bypassing the client’s nose Correct D. Prevent fluid loss from the lungs during mouth breathing Awarded 1.0 points out of 1.0 possible points. 95. 95.ID: 9477054219 A client’s baseline vital signs are temperature 98° F oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever of 103° F. Which respiratory rate would the nurse anticipate as part of the body’s response to the change in client status? A. 12 breaths/min B. 16 breaths/min C. 18 breaths/min D. 22 breaths/min Correct Awarded 1.0 points out of 1.0 possible points. 96. 96.ID: 9477052817 A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could cause which effect? A. Be drying to nasal passages B. Decrease the client’s oxygen­based respiratory drive Correct C. Increase the risk of pneumonia as a result of drier air passages D. Decrease the client’s carbon dioxide–based respiratory drive Awarded 1.0 points out of 1.0 possible points. 97. 97.ID: 9477045854 A nurse is reading the chest x­ray report of a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse interprets that the tube is positioned above which anatomical area? A. The first tracheal cartilaginous ring B. The point where the larynx connects to the trachea C. The bifurcation of the right and left main stem bronchi Correct D. The area connecting the oropharynx to the laryngopharynx Awarded 1.0 points out of 1.0 possible points. 98. 98.ID: 9477051434 A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume? A. Pulse rate Correct B. Blood pressure C. Pulmonary artery systolic pressure D. Pulmonary artery end­diastolic pressure Awarded 1.0 points out of 1.0 possible points. 99. 99.ID: 9477049128 A nurse is admitting a client with a diagnosis of hypothermia to the hospital. Which signs does the nurse anticipate that this client will exhibit? A. Increased heart rate and increased blood pressure Incorrect B. Increased heart rate and decreased blood pressure C. Decreased heart rate and increased blood pressure D. Decreased heart rate and decreased blood pressure Correct Awarded 0.0 points out of 1.0 possible points. 100. 100.ID: 9477054210 A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client’s neck primarily for which reason? A. It is unnecessary to use both hands B. Feeling dual pulsations may lead to an incorrect measurement C. Palpating both carotid pulses simultaneously could occlude the trachea D. Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop Correct Awarded 1.0 points out of 1.0 possible points. Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9477054249 A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright­red blood. The nurse should take which immediate action? A. Notify the surgeon Correct B. Continue the assessment C. Check the client’s blood pressure D. Obtain a flashlight, gauze, and a curved hemostat Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 9477051455 A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action? A. Preparing the client for a perfusion scan B. Attaching the client to a cardiac monitor C. Administering oxygen by way of nasal cannula Correct D. Ensuring that the intravenous (IV) line is patent Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9477051498 A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply). A. Clamp the chest tube B. Chang the drainage system C. Assess the system for an external air leak Correct D. Reduce the degree of suction being applied E. Document assessment findings, actions taken, and client response Correct Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an external air leak if constant bubbling were noted in this chamber. If an external air leak is not present and the air leak is a new occurrence, the health care provider is notified immediately, because an air leak may be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect. Additionally, a chest tube is not clamped unless this has been specifically prescribed in the agency’s policies and procedures. Changing the drainage system will not alleviate the problem. Reducing the degree of suction being applied will not affect the bubbling in the water seal chamber and could be harmful. The nurse would document the assessment findings and interventions taken in the client’s medical record. Test­Taking Strategy: Focus on the data in the question, noting that there is bubbling in the water seal chamber. Use knowledge regarding the priority actions in the care of a closed chest tube drainage system. Recalling that this may indicate an air leak will direct you to the correct options. Review the nursing actions to be taken immediately in the event that complications of a closed chest tube drainage system occur Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situation/Management Giddens Concepts: Care Coordination, Gas Exchange HESI Concepts: Nursing Interventions, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., p. 546). St. Louis: Mosby. Awarded 2.0 points out of 2.0 possible points. 5. 5.ID: 9477055619 A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action? A. Reinsert the chest tube B. Contact the health care provider C. Transfer the client back to bed D. Cover the insertion site with a sterile occlusive dressing Correct Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9477047967 A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first? A. Continue suctioning to remove the blood B. Check the degree of suction being applied Correct C. Encourage the client to cough out the bloody secretions D. Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth Rationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs, the nurse should first assess the client and then determine the degree of suction being applied. The degree of suction pressure may need to be decreased. The nurse must also remember to apply intermittent suction and perform catheter rotation during suctioning. Continuing the suctioning or performing vigorous suctioning through the mouth will result in increased trauma and therefore increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody secretions. Test­Taking Strategy: Note the strategic word, first. Eliminate the options of continuing the suctioning to remove the blood and removing the suction catheter from the nose to begin vigorous suctioning through the mouth, because they are comparable or alike. Next eliminate the option that involves encouraging the client to cough out the bloody secretions, because it is unlikely that the client will be able to do so. Review the nursing actions to be taken immediately in the event of a complication during suctioning Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Respiratory Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision­Making/Clinical Judgment, Oxygenation/Gas Exchange Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 629, 635). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 9477054269 A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client’s trachea but is unable to do so. Which action should the nurse take first? A. Call a code B. Contact the health care provider C. Administer a bronchodilator D. Disconnect the suction source from the catheter Correct Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 9477044479 A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which action should the nurse take first? A. Contact the health care provider B. Check for kinks in the drainage system Correct C. Check the client’s blood pressure and heart rate D. Connect a new drainage system to the client’s chest tube Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: 9477047216 A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take which action first? A. Call the health care provider B. Increase the rate of the IV infusion C. Check the client’s overall intake and output record Correct D. Administer a 250­mL bolus of normal saline solution (0.9%) Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 9477054279 A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? A. Check the client’s blood pressure B. Check the oxygen saturation level C. Have the client take some deep breaths D. Lower the head of the bed slowly until the dizziness is relieved Correct Awarded 1.0 points out of 1.0 possible points. 11. 11.ID: 9477047901 A nurse is preparing for intershift report when an unlicensed assistive personnel (UAP) pulls an emergency call light in a client’s room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client’s blood pressure is 88/60 mm Hg. Which action should the nurse take first? A. Call the health care provider B. Check the hourly urine output C. Check the IV site for infiltration D. Place the client in a modified Trendelenburg position Correct Awarded 1.0 points out of 1.0 possible points. 12. 12.ID: 9477052857 A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assess first? A. The client’s vital signs B. The amount of drainage C. The client’s lung sounds D. The chest tube connections Correct Awarded 1.0 points out of 1.0 possible points. 13. 13.ID: 9477055641 A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing? A. Steak B. Veal C. Cheese D. Oranges Correct Awarded 1.0 points out of 1.0 possible points. 14. 14.ID: 9477054227 A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The health care provider has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client’s room before allowing the client to drink? A. Straw B. Napkin C. Suction equipment Correct D. Oxygen saturation monitor Awarded 1.0 points out of 1.0 possible points. 15. 15.ID: 9477052847 A client in the postanesthesia care unit has an as­needed prescription for ondansetron. Which occurrence would prompt the nurse to administer this medication to the client? A. Paralytic ileus B. Incisional pain C. Urine retention D. Nausea and vomiting Correct Awarded 1.0 points out of 1.0 possible points. 16. 16.ID: 9477050283 A nurse administers scopolamine as prescribed to a client. For which side effect of this medication does the nurse monitor the client? A. Pupil constriction B. Increased urine output C. Complaints of dry mouth Correct D. Complaints of feeling sweaty Awarded 1.0 points out of 1.0 possible points. 17. 17.ID: 9477047248 A nurse is preparing a client for transfer to the operating room. Which action should the take in the care of this client at this time? A. Ensuring that the client has voided Correct B. Administering all daily medications C. Practicing postoperative breathing exercises D. Verifying that the client has not eaten for the last 24 hours Awarded 1.0 points out of 1.0 possible points. 18. 18.ID: 9477045874 A nurse receives a telephone call from a nurse on the post­anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client? A. Assess the patency of the airway Correct B. Check tubes and drains for patency C. Check the dressing for bleeding D. Assess the vital signs to compare them with preoperative measurements Awarded 1.0 points out of 1.0 possible points. 19. 19.ID: 9477045891 A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above which value? A. 85% B. 89% C. 95% Correct D. 100% Awarded 1.0 points out of 1.0 possible points. 20. 20.ID: 9477052876 A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon’s office? Select all that apply. A. Hematocrit 30% (0.30) Correct B. Sodium 141 mEq/L (141 mmol/L) C. Hemoglobin 8.9 g/dL (89 g/L) Correct D. Platelets 210× 103/μL (210 × 109/L) E. Serum creatinine 0.8 mg/dL (70 μmol/L) Awarded 2.0 points out of 2.0 possible points. 21. 21.ID: 9477052865 A client has been scheduled for magnetic resonance imaging (MRI). For which condition, a contraindication to MRI, does the nurse check the client’s medical history? A. Pancreatitis B. Pacemaker insertion Correct C. Type 1 diabetes mellitus D. Chronic airway limitation Awarded 1.0 points out of 1.0 possible points. 22. 22.ID: 9477047238 A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure? A. Flat Correct B. Semi­Fowler C. Side­lying, with the head of the bed elevated D. Sitting up in a recliner with the feet elevated Awarded 1.0 points out of 1.0 possible points. 23. 23.ID: 9477051477 A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which action should the nurse plan to take as part of routine after­care for this client? A. Administering a laxative B. Encouraging fluid intake Correct C. Maintaining the client on strict bed rest D. Holding all medications for at least 2 hours Awarded 1.0 points out of 1.0 possible points. 24. 24.ID: 9477043192 A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test? A. “I didn’t shampoo my hair.” Correct B. “I ate breakfast this morning.” C. “I didn’t take my anticonvulsant today.” D. “It was hard not to drink coffee this morning, but I knew that I couldn’t, so I didn’t.” Awarded 1.0 points out of 1.0 possible points. 25. 25.ID: 9477049148 Blood is drawn from a male client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level? A. 1.7 mg/dL (101.2 μmol/L) B. 4.4 mg/dL (262 μmol/L) Correct C. 8.9 mg/dL (529.9 μmol/L) D. 12.8 mg/dL (762.1 μmol/L) Awarded 1.0 points out of 1.0 possible points. 26. 26.ID: 9477051424 A nurse is providing post­procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should provide the client with which information? A. To resume full activity the next day B. Not to eat or drink anything until the next morning C. To keep the shoulder completely immobilized for the rest of the day D. To report to the health care provider the development of fever or redness and heat at the site Correct Awarded 1.0 points out of 1.0 possible points. 27. 27.ID: 9477044448 A client is tested for HIV with the use of an enzyme­linked immunosorbent assay (ELISA), and the test result is positive. The nurse should provide which information to the client about the test? A. HIV infection has been confirmed B. The client probably has an opportunistic infection C. The test will need to be confirmed with the use of a Western blot Correct D. A positive test is a normal result and does not mean that the client is infected with HIV Awarded 1.0 points out of 1.0 possible points. 28. 28.ID: 9477047259 A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells per cubic millimeter of blood. The nurse interprets this test result as indicating which? A. Improvement in the client B. The need for antiretroviral therapy Correct C. The need to discontinue antiretroviral therapy D. An effective response to the treatment for HIV Awarded 1.0 points out of 1.0 possible points. 29. 29.ID: 9477044498 A client has just undergone a renal biopsy. Which intervention should the nurse include in the post­ procedure plan of care? A. Restricting fluid intake for the first 24 hours B. Periodically testing the urine for occult blood Correct C. Avoiding the administration of opioid analgesics D. Having the client ambulate in the room and hall for short distances Awarded 1.0 points out of 1.0 possible points. 30. 30.ID: 9477050216 A nurse has a prescription to collect a 24­hour urine specimen from a client. Which measure should the nurse take during this procedure? A. Keeping the specimen at room temperature B. Saving the first urine specimen collected at the start time C. Discarding the last voided specimen at the end of the collection time D. Asking the client to void, discarding the specimen, and noting the start time Correct Awarded 1.0 points out of 1.0 possible points. 31. 31.ID: 9477047283 A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important? A. Administering a sedative B. Encouraging fluid intake C. Administering an oral preparation of radiopaque dye D. Questioning the client about allergies to iodine or shellfish Correct Awarded 1.0 points out of 1.0 possible points. 32. 32.ID: 9477044488 A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which finding should the nurse assess the client? A. Bleeding Correct B. Renal colic C. Infection at the site D. Increased temperature Awarded 1.0 points out of 1.0 possible points. 33. 33.ID: 9477049161 A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting which finding? A. Urine output of 40 mL/hr B. Blood pressure of 118/76 mm Hg C. Respiratory rate of 18 breaths/min D. Pallor and coolness of the right leg Correct Awarded 1.0 points out of 1.0 possible points. 34. 34.ID: 9477054237 A nurse reviews a client’s urinalysis report. Which finding does the nurse recognize as abnormal? A. pH of 6.0 B. An absence of protein C. The presence of ketones Correct D. Specific gravity of 1.018 Awarded 1.0 points out of 1.0 possible points. 35. 35.ID: 9477055631 A nurse provides information to a client who is scheduled for cardiac catheterization to rule out coronary occlusion. The nurse should provide which information to the client? A. The procedure is performed in the operating room B. It is necessary to lie quietly on a hard x­ray table for about 4 hours C. The room is bright and well lit, and it is best to keep the eyes closed D. The client may have feelings of warmth or flushing during the procedure Correct Awarded 1.0 points out of 1.0 possible points. 36. 36.ID: 9477051487 A client who has sustained a myocardial infarction is scheduled to have an echocardiogram. Which measure should the nurse take before the procedure? A. Imposing nothing­by­mouth (NPO) status for 4 hours B. Asking the client to sign an informed consent form C. Asking the client about a history of allergy to iodine or shellfish D. Telling the client that the procedure is painless and takes 30 to 60 minutes to complete Correct Awarded 1.0 points out of 1.0 possible points. 37. 37.ID: 9477052827 A nurse in a health care provider’s office has just made an appointment for a client to undergo an exercise stress test. The nurse, in providing pre­procedure teaching, should provide which information to the client? A. Wear sweatpants and a heavy sweatshirt B. Eat a small meal just before the procedure C. Wear comfortable rubber­soled shoes such as sneakers Correct D. Avoid consuming caffeine for 30 minutes before the procedure Awarded 1.0 points out of 1.0 possible points. 38. 38.ID: 9477047944 A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24­hour period. What steps should the nurse take to initiate this prescription? Select all that apply. A. Giving the client a device holder to wear around the waist B. Giving the client a diary in which to record activity and symptoms C. Telling the client to rest as much as possible during the next 24 hours D. Instructing the client to enclose the monitor in plastic wrap before taking a bath E. Telling the client that occasional slight shocks from the monitor will be felt but that they are harmless Incorrect Awarded 1.0 points out of 2.0 possible points. 39. 39.ID: 9477044432 A client has undergone pericardiocentesis to treat cardiac tamponade. For which signs should the nurse assess the client to determine whether the tamponade is recurring? A. Decreasing pulse B. Rising blood pressure C. Distant muffled heart sounds Correct D. Falling central venous pressure (CVP) Awarded 1.0 points out of 1.0 possible points. 40. 40.ID: 9477051443 A nurse is watching as an unlicensed assistive personnel (UAP) measure the blood pressure (BP) of a hypertensive client. Which actions on the part of the UAP would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply. A. Measuring the BP after the client has sat quietly for 5 minutes B. Having the client sit with the arm bared and supported at heart level C. Used a cuff with a rubber bladder that encircles at least 60% of the limb Correct D. Measuring the BP after the client reports that he just drank a cup of coffee Correct E. Allowing the client to talk as the blood pressure is being measured Correct Awarded 3.0 points out of 3.0 possible points. 41. 41.ID: 9477044422 A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply. A. Setting the suction pressure to 60 mm Hg Correct B. Applying suction throughout the procedure Correct C. Assessing breath sounds before suctioning D. Placing the client in a supine position before the procedure Correct E. Hyperoxygenating the client with 100% oxygen before suctioning Awarded 3.0 points out of 3.0 possible points. 42. 42.ID: 9477047996 Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse checks the health care provider’s prescriptions to ensure that the prescribed flow is not greater than which liter (L) per minute (min)? A. 1 L/min B. 3 L/min Correct C. 4 L/min D. 6 L/min Awarded 1.0 points out of 1.0 possible points. 43. 43.ID: 9477049138 A client who experienced the sudden onset of respiratory distress has been intubated with an endotracheal tube. After the tube is placed in the trachea, the nurse should take which immediate action? A. Tape the tube in place B. Send the client for a chest x­ray C. Note how far the tube has been inserted D. Auscultate both lungs for the presence of breath sounds Correct Awarded 1.0 points out of 1.0 possible points. 44. 44.ID: 9477054296 A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication of which? A. The tube is patent Correct B. There is probably a kink in the tubing C. Suction should be added to the system D. The client is retaining airway secretions Awarded 1.0 points out of 1.0 possible points. 45. 45.ID: 9477045845 A nurse is performing nasotracheal suctioning on a client. Which observations should be cause for concern to the nurse? Select all that apply. A. The client becomes cyanotic. Correct B. Secretions are becoming bloody. Correct C. The client gags during the procedure. D. Clear to opaque secretions are removed. E. The heart rate varies from 80 to 82 beats/min. Awarded 2.0 points out of 2.0 possible points. 46. 46.ID: 9477044402 A nurse is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which coexisting problem is cause for the nurse to suspect that the oxygen saturation readings are not entirely accurate? A. Infection B. Hypertension C. Low blood pressure Correct D. Loss of cough reflex Awarded 1.0 points out of 1.0 possible points. 47. 47.ID: 9477047910 A nurse is reading the radiology report of a client with a chest tube attached to a closed drainage system who has undergone a chest x­ray. The report states that the client’s affected lung is fully reexpanded. The nurse anticipates that the assessment of the chest tube system will reveal which finding? A. No fluctuation in the water seal chamber Correct B. Continuous bubbling in the water seal chamber C. Increased drainage in the collection chamber D. Continuous gentle suction in the suction control chamber Awarded 1.0 points out of 1.0 possible points. 48. 48.ID: 9477050297 A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client? A. Assessing the client’s chest for crepitus once every 24 hours B. Taping the connections between the chest tube and the drainage system Correct C. Adding 20 mL of sterile water to the suction control chamber every shift D. Recording the volume of secretions in the drainage collection chamber every 24 hours Awarded 1.0 points out of 1.0 possible points. 49. 49.ID: 9477045827 A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse most concerned? A. Oxygen saturation of 97% B. Equal breath sounds in both lungs C. Absence of cough and gag reflexes Correct D. Respiratory rate of 20 breaths/min Awarded 1.0 points out of 1.0 possible points. 50. 50.ID: 9477051465 A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion through the right femoral vein. The nurse assesses for allergic reaction to the contrast medium by monitoring for the presence of which? A. Bradycardia B. Respiratory distress Correct C. Hematoma in the right groin D. Discomfort in the right groin Awarded 1.0 points out of 1.0 possible points. 51. 51.ID: 9477045862 A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the health care provider? Select all that apply. A. Unequal chest expansion Correct B. Pulse rate of 82 beats/min C. Respiratory rate of 22 breaths/min D. Diminished breath sounds in the right lung Correct E. Complaints of discomfort at the needle insertion site Awarded 2.0 points out of 2.0 possible points. 52. 52.ID: 9477050273 A nurse is monitoring a client who has undergone pleural biopsy. Which finding causes the nurse to suspect that the client is experiencing a complication? A. Warm, dry skin B. Mild pain at the biopsy site C. Complaints of shortness of breath Correct D. Capillary refill time of less than 3 seconds Awarded 1.0 points out of 1.0 possible points. 53. 53.ID: 9477050204 A client has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority? A. Ambulating the client B. Administering pain medication C. Encouraging copious fluid intake D. Checking for the return of the gag reflex Correct Awarded 1.0 points out of 1.0 possible points. 54. 54.ID: 9477044412 A client is receiving intermittent bolus feedings by way of a nasogastric tube. In which position should the nurse place the client once the feeding is complete? A. Supine B. Head of bed flat C. Left lateral position D. Head of bed elevated 30 to 45 degrees Correct Awarded 1.0 points out of 1.0 possible points. 55. 55.ID: 9477052837 A nurse has a prescription to discontinue a client’s nasogastric tube. The nurse auscultates the client’s bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath and do what? A. Exhale during tube removal B. Bear down during tube removal C. Hold the breath during tube removal Correct D. Breathe normally during tube removal Awarded 1.0 points out of 1.0 possible points. 56. 56.ID: 9477047274 A nurse checks the residual volume from a client’s nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client? A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed Correct B. Discard the residual volume properly and record it as output on the client’s fluid balance record C. Dilute the residual volume with water and inject it into the nasogastric tube, applying pressure on the plunger D. Mix the residual volume with the formula and pour it into the nasogastric tube, using a syringe without a plunger Awarded 1.0 points out of 1.0 possible points. 57. 57.ID: 9477045807 A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily? A. Placing the tube in warm water B. Hyperextending the head while inserting the tube C. Removing the tube if any resistance to insertion is met D. Asking the client to swallow as the tube is being advanced Correct Awarded 1.0 points out of 1.0 possible points. 58. 58.ID: 9477050235 A client who has undergone an esophagogastroduodenoscopy (EGD) returns from the endoscopy department. After checking the client’s gag reflex, which action should the nurse take? A. Taking the client’s vital signs Correct B. Giving the client a drink of water C. Monitoring the client for a sore throat D. Being alert to complaints of heartburn Awarded 1.0 points out of 1.0 possible points. 59. 59.ID: 9477044440 A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply. A. That informed consent is required Correct B. That the test takes about 4 hours to complete C. That no premedication for sedation will be necessary D. That food and fluids will be withheld before the procedure Correct E. That multiple position changes may be necessary to pass the tube Correct Awarded 3.0 points out of 3.0 possible points. 60. 60.ID: 9477052808 A client is scheduled for a barium swallow (esophagography) in 2 days. The nurse, providing preprocedure instructions, should tell the client to implement which measure? A. Eat a regular supper and breakfast B. Remove all metal and jewelry before the test Correct C. Expect diarrhea for a few days after the procedure D. Take all oral medications as scheduled with milk on the day of the test Awarded 1.0 points out of 1.0 possible points. 61. 61.ID: 9477050225 A nurse is preparing a client for colonoscopy. Into which position does the nurse assist the client for the procedure? A. Left Sims’ position Correct B. Lithotomy position C. Knee­chest position D. Right Sims’ position Awarded 1.0 points out of 1.0 possible points. 62. 62.ID: 9477047226 Polyethylene glycol–electrolyte solution is prescribed for a hospitalized client scheduled for colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate? A. Administering a cleansing enema. B. Calling the health care provider C. Documenting the diarrhea in the medical record Correct D. Giving intravenous replacement fluids in large amounts Awarded 1.0 points out of 1.0 possible points. 63. 63.ID: 9477047921 A health care provider is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client? A. Supine B. Upright Correct C. Left side–lying D. Right side–lying Awarded 1.0 points out of 1.0 possible points. 64. 64.ID: 9477054290 A nurse is reviewing the results of serum laboratory studies of a client with suspected hepatitis. Which increased parameter is interpreted by the nurse as the most specific indicator of this disease? A. Hemoglobin B. Serum bilirubin Correct C. Blood urea nitrogen (BUN) D. Erythrocyte sedimentation rate (ESR) Awarded 1.0 points out of 1.0 possible points. 65. 65.ID: 9477050290 A nurse is preparing to examine a client’s skin using a Wood light. What should the nurse do to facilitate this procedure? A. Darken the examining room Correct B. Administer a local anesthetic C. Obtain a signed informed consent D. Shave the skin and scrub it with povidone­iodine (Betadine) Awarded 1.0 points out of 1.0 possible points. 66. 66.ID: 9477049118 A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than which value? A. 7% Correct B. 9% C. 10% D. 15% Awarded 1.0 points out of 1.0 possible points. 67. 67.ID: 9477051407 A client with diabetes mellitus is scheduled to have blood drawn in the morning for a fasting blood glucose determination. What does the nurse tell the client that it is acceptable to consume on the morning of the test? A. Water Correct B. Tea without any sugar C. Coffee without any milk D. Clear liquids such as apple juice Awarded 1.0 points out of 1.0 possible points. 68. 68.ID: 9477047985 A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should provide the client with which information about the test? A. The test may be painful B. The test takes 2 to 3 hours C. Food and fluids are not allowed for 4 hours after the test D. Dye is injected and may cause a warm flushing sensation Correct Awarded 1.0 points out of 1.0 possible points. 69. 69.ID: 9477047292 A pelvic ultrasound is prescribed to evaluate a client’s ovarian mass. What should the nurse giving preprocedure instructions tell the client that it important to do before the procedure? A. Eat only a light breakfast B. Wear comfortable clothing and shoes C. Drink 6 to 8 glasses of water without voiding Correct D. Stop eating or drinking at midnight before the test Awarded 1.0 points out of 1.0 possible points. 70. 70.ID: 9477043178 A client has been given a diagnosis of multiple myeloma. Which result does the nurse reviewing the client’s laboratory findings recognize as being specifically related to this diagnosis? A. Increased calcium level Correct B. Decreased blood urea nitrogen (BUN) C. Increased white blood cell (WBC) count D. Decreased number of plasma cells in the bone marrow Awarded 1.0 points out of 1.0 possible points. 71. 71.ID: 9477050248 A woman has been scheduled for a routine mammogram. The nurse should provide the client with which information about the test? A. That mammography takes about 1 hour B. Not to eat or drink on the morning of the test C. That there is no discomfort associated with the procedure D. That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test Correct Awarded 1.0 points out of 1.0 possible points. 72. 72.ID: 9477049153 A client has made an appointment to for her annual Papanicolaou test (a.k.a. Pap smear). The nurse who schedules the appointment should provide which information to the client? A. Vaginal douching is required an hour before the test B. Spicy foods should not be eaten on the day of the test C. The test has absolutely no discomfort associated with it D. The test cannot be performed while the client is menstruating Correct Awarded 1.0 points out of 1.0 possible points. 73. 73.ID: 9477055681 A client who has just undergone a skin biopsy is listening to discharge instructions from the nurse. The nurse determines that the client needs further teachingif the client indicates that he plans to do what as part of aftercare? A. Use the antibiotic ointment as prescribed B. Return in 7 days to have the sutures removed C. Apply cool compresses to the site twice a day for 20 minutes Correct D. Call the health care provider if excessive drainage from the wound occurs Rationale: Cool compresses are not used on biopsy sites. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After dressing removal, the site is kept clean and dry but may be cleansed daily with tap water or saline solution. The health care provider may prescribe an antibiotic ointment to minimize local bacterial colonization, and the ointment should be used as directed. The nurse instructs the client to report any redness or excessive drainage at the site. Sutures are usually removed 7 to 10 days after biopsy. Test­Taking Strategy: Note the strategic words, needs further teaching. These words indicate a negative event query and the need to select the incorrect client statement. Recalling that the biopsy site should be kept dry will direct you to the correct option. Review aftercare instructions for skin biopsy. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care: Diagnostic Tests Giddens Concepts: Client Teaching, Clinical Judgment HESI Concepts: Clinical Decision Making/Clinical Judgment, Teaching and Learning/Patient Education Reference: Ignatavicius, D., & Workman, M. (2013). Medical­surgical nursing: Patient­centered collaborative care. (7th ed., p. 468). St. Louis: Saunders. @ Rationale: Cool compresses are not used on biopsy sites. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After dressing removal, the site is kept clean and dry but may be cleansed daily with tap water or saline solution. The health care provider may prescribe an antibiotic ointment to minimize local bacterial colonization, and the ointment should be used as directed. The nurse instructs the client to report any redness or excessive drainage at the site. Sutures are usually removed 7 to 10 days after biopsy. Test­Taking Strategy: Note the strategic words, needs further teaching. These words indicate a negative event query and the need to select the incorrect client statement. Recalling that the biopsy site should be kept dry will direct you to the correct option. Review aftercare instructions for skin biopsy. Level of Cognitive Ability: Evaluating Awarded 1.0 points out of 1.0 possible points. 74. 74.ID: 9477049172 A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin. Which result indicates that the prescribed dose of phenytoin is therapeutic? A. 3 mcg/mL B. 8 mcg/mL C. 16 mcg/mL Correct D. 28 mcg/mL Awarded 1.0 points out of 1.0 possible points. 75. 75.ID: 9477044458 A client is receiving a continuous IV infusion of heparin for the treatment of deep vein thrombosis. The client’s activated partial thromboplastin time (aPTT) level is 88 seconds (88 seconds). The client’s baseline before the initiation of therapy was 30 seconds (30 seconds). Which action does the nurse anticipate is needed? A. Shutting off the heparin infusion B. Increasing the rate of the heparin infusion C. Decreasing the rate of the heparin infusion Correct D. Leaving the rate of the heparin infusion as is Incorrect Rationale: The normal aPTT varies between 25 and 35 seconds (25 and 35 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is designed to keep the aPTT between 1.5 and 2.5 times normal. Therefore the client’s aPTT is somewhat increased but does not indicate a critical value. The infusion rate should be slowed and the aPTT rechecked as prescribed. A persistently increased aPTT indicates a risk for bleeding. Test­Taking Strategy: Focus on the data in the question. To answer this question accurately, it is necessary to be familiar with both the normal aPTT level and the therapeutic level needed after the institution of heparin therapy. Noting that the client’s baseline before the initiation of therapy was 30 seconds and recalling that the therapeutic dose for this client is intended to keep the aPTT between 1.5 and 2.5 times normal will direct you to the correct option. Review the content related to heparin therapy. Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Pharmacology: Cardiovascular Medications Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision Making/Clinical Judgment, Evidence Based Practice/Evidence References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp. 568­570) St. Louis: Saunders. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., p. 627). St. Louis: Mosby. @ Rationale: The normal aPTT varies between 25 and 35 seconds (25 and 35 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is designed to keep the aPTT between 1.5 and 2.5 times normal. Therefore the client’s aPTT is somewhat increased but does not indicate a critical value. The infusion rate should be slowed and the aPTT rechecked as prescribed. A persistently increased aPTT indicates a risk for bleeding. Test­Taking Strategy: Focus on the data in the question. To answer this question accurately, it is necessary to be familiar with both the normal aPTT level and the therapeutic level needed after the institution of heparin therapy. Noting that the client’s baseline before the initiation of therapy was 30 seconds and recalling that the therapeutic dose for this client is intended to keep the aPTT between and 2.5 times normal will direct you to the correct option. Review the content related to heparin therapy. Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Awarded 0.0 points out of 1.0 possible points. 76. 76.ID: 9477047975 A client with cardiovascular disease is scheduled to receive a daily dose of furosemide. Which potassium level would cause the nurse, reviewing the client’s electrolyte values, to contact the health care provider before administering the dose? A. 3.0 mEq/L (3.0 mmol/L) Correct B. 3.8 mEq/L (3.8 mmol/L) C. 4.2 mEq/L (4.2 mmol/L) D. 5.2 mEq/L (5.2 mmol/L) Rationale: The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L(3.5 to 5.0 mmol/L). A result of 3.0 mEq/L (3.0 mmol/L)is low, 3.8 and 4.2 mEq/L (3.8 and 4.2 mmol/L) are normal, and 5.2 mEq/L (5.2 mmol/L)is high. Administering furosemide to a client with a low potassium level and a history of cardiovascular disease could precipitate ventricular dysrhythmias in the client. The normal and high levels do not require withholding of the dose. In fact, the high level may be lowered by administration of the medication, which is a potassium­losing diuretic. Test­Taking Strategy: Focus on the subject, the need to call the health care provider. Knowledge of the normal serum potassium level is needed to answer this question. This will assist you in identifying the value that is not within normal range. Recalling the effects of furosemide on the serum potassium level will also help you find the correct option. Review the potassium laboratory value and the effects of furosemide on the potassium level. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of Care: Laboratory Values Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision Making/Clinical Judgment, Evidence Based Practice/Evidence References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp. 530­532) St. Louis: Saunders. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., p. 296). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 77. 77.ID: 9477045817 A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the total cholesterol level should be maintained at less than which value? A. 140 mg/dL (<3.64 mmol/L) Incorrect B. 200 mg/dL (<5.2 mmol/L) Correct C. 250 mg/dL (<6.5 mmol/L) D. 300 mg/dL (<7.8 mmol/L) Awarded 0.0 points out of 1.0 possible points. 78. 78.ID: 9477047268 A nurse is reviewing the results of renal function testing in a client with renal calculi. Which finding indicates to the nurse that the client’s blood urea nitrogen (BUN) level is within the normal range? A. 2 mg/dL (0.7 mmol/L) B. 18 mg/dL (6.3 mmol/L) Correct C. 25 mg/dL (8.75 mmol/L) D. 35 mg/dL (12.25 mmol/L) Awarded 1.0 points out of 1.0 possible points. 79. 79.ID: 9477049108 An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse who receives the report of the client’s laboratory work that the client’s hematocrit is normal? A. 10% ( 0.10) B. 22% ( 0.22) C. 30% ( 0.30) D. 43% ( 0.43) Correct Awarded 1.0 points out of 1.0 possible points. 80. 80.ID: 9477045837 A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for several serum laboratory tests. Which serum amylase value, noted by the nurse reviewing the results, would be expected in this client at this time? A. 48 units/L (0.816 μkat/L) B. 97 units/L (1.649 μkat/L) C. 150 units/L (2.55 μkat/L) D. 395 units/L (6.715 μkat/L) Correct Awarded 1.0 points out of 1.0 possible points. 81. 81.ID: 9477045883 A nurse is reviewing laboratory results for a client who is at risk for nephrotoxicity because of medications being taken. Which serum creatinine result does the nurse document as normal? A. 0.2 mg/dL (17.6 μmol/L) B. 1.0 mg/dL (88.3 μmol/L) Correct C. 2.8 mg/dL (247.3 μmol/L) D. 3.9 mg/dL (344.5 μmol/L) Awarded 1.0 points out of 1.0 possible points. 82. 82.ID: 9477050254 A client with type 1 diabetes mellitus has a blood glucose level of 620 mg/dL (34.4 mmol/L). After the nurse calls the health care provider to report the finding and monitors the client closely for which condition? A. Metabolic acidosis Correct B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis Awarded 1.0 points out of 1.0 possible points. 83. 83.ID: 9477050263 A nurse reviews the blood gas results of a client in respiratory distress. The pH is 7.32 and the PaCO2 is 50 mm Hg (6.65 kPa). Which acid­base imbalance does the nurse recognize in these findings? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis Correct D. Respiratory alkalosis Awarded 1.0 points out of 1.0 possible points. 84. 84.ID: 9477049195 Blood for arterial blood gas determinations is drawn on a client with pneumonia, and testing reveals a pH of 7.45, PaCO2 of 30 mm Hg (3.99 kPa)., and HCO3 of 19 mEq/L (19 mmol/L). The nurse interprets these results as indicative of which disorder? A. Compensated metabolic acidosis Incorrect B. Compensated respiratory alkalosis Correct C. Uncompensated metabolic alkalosis D. Uncompensated respiratory acidosis Awarded 0.0 points out of 1.0 possible points. 85. 85.ID: 9477052887 A nurse is caring for a client who is vomiting. For which acid­base imbalance does the nurse assess the client? A. Metabolic acidosis B. Metabolic alkalosis Correct C. Respiratory acidosis D. Respiratory alkalosis Awarded 1.0 points out of 1.0 possible points. 86. 86.ID: 9477045899 A nurse is caring for a client with diarrhea. For which acid­base disorder does the nurse assess the client? A. Metabolic acidosis Correct B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis Awarded 1.0 points out of 1.0 possible points. 87. 87.ID: 9477055607 A client tells the nurse that he has been experiencing frequent heartburn and has been “living on antacids.” For which acid­base disturbance does the nurse recognize a risk? A. Metabolic acidosis B. Metabolic alkalosis Correct C. Respiratory acidosis D. Respiratory alkalosis Awarded 1.0 points out of 1.0 possible points. 88. 88.ID: 9477049184 A client has the following arterial blood gas (ABG) results: pH 7.51, PaCO231 mm Hg (4.12 kPa), PaO2 94 mm Hg (12.45 kPa), HCO3 24 mEq/L (24 mmol/L). Which acid­base disturbance does the nurse recognize in these results? A. Metabolic acidosis B. Metabolic alkalosis Incorrect C. Respiratory acidosis D. Respiratory alkalosis Correct Awarded 0.0 points out of 1.0 possible points. 89. 89.ID: 9477047932 A client with histoplasmosis has the following arterial blood gas (ABG) results: pH 7.30, PaCO2 58 mm Hg (7.72 kPa), PaO2 75 mm Hg (9.93 kPa), HCO3 26 mEq/L (26 mmol/L). Which acid­base disturbance does the nurse recognize in these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis Correct D. Respiratory alkalosis Rationale: The normal pH is 7.35 to 7.45. The normal PaCO2 is 35­45 mm Hg (4.66­5.98 kPa). The normal HCO3 (bicarbonate) is 22­26 mEq/L (22­26 mmol/L). The normal PaO2 is 80­100 mm Hg (10.6­13.33 kPa). Acidosis is defined as a pH of less than 7.35; alkalosis is defined as a pH greater than 7.45. In a respiratory condition, an opposite effect is seen between the pH and the PCO2. In respiratory acidosis, the pH is decreased and the PCO2 is increased. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L (22mmol/L); metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L (26 mmol/L). This client’s ABG values are consistent with respiratory acidosis. Test­Taking Strategy: Focus on the subject, interpreting blood gas values. Note the client’s diagnosis and recall that this client will have difficulty exchanging oxygen and carbon dioxide. This will help you eliminate metabolic acidosis and metabolic alkalosis. To select from the remaining options, remember that the pH is decreased with acidosis. This will direct you to the correct option. Review the steps involved in interpreting blood gas values. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Fundamentals of Care: Acid­Base Giddens Concepts: Acid/Base, Clinical Judgment HESI Concepts: Acid/Base, Clinical Decision Making/Clinical Judgment Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., p. 304). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 90. 90.ID: 9477044470 A client is brought to the emergency department by a neighbor. The client is lethargic and has a fruity odor on the breath. The client’s arterial blood gas (ABG) results are pH 7.25, PaCO234 mm Hg (4.52 kPa), PaO2 86 mm Hg (11.3 kPa), HCO3 14 mEq/L (14 mmol/L). Which acid­base disturbance does the nurse recognize in these results? A. Metabolic acidosis Correct B. Metabolic alkalosis C. Respiratory acidosis Incorrect D. Respiratory alkalosis Awarded 0.0 points out of 1.0 possible points. 91. 91.ID: 9477047956 A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias Correct D. Dysrhythmias and decreased respiratory rate and depth Awarded 1.0 points out of 1.0 possible points. 92. 92.ID: 9477054259 A client with a history of lung disease is at risk for respiratory acidosis. For which signs and symptoms does the nurse assess this client? A. Disorientation and dyspnea Correct B. Drowsiness, headache, and tachypnea Incorrect C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth Awarded 0.0 points out of 1.0 possible points. 93. 93.ID: 9477055651 A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. For which signs and symptoms does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth Correct Awarded 1.0 points out of 1.0 possible points. 94. 94.ID: 9477051415 A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to promote which goal? A. Prevent the client from getting a nosebleed B. Give the client added fluid by way of the respiratory tree C. Humidify the oxygen that is bypassing the client’s nose Correct D. Prevent fluid loss from the lungs during mouth breathing Awarded 1.0 points out of 1.0 possible points. 95. 95.ID: 9477054219 A client’s baseline vital signs are temperature 98° F oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever of 103° F. Which respiratory rate would the nurse anticipate as part of the body’s response to the change in client status? A. 12 breaths/min B. 16 breaths/min C. 18 breaths/min D. 22 breaths/min Correct Awarded 1.0 points out of 1.0 possible points. 96. 96.ID: 9477052817 A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could cause which effect? A. Be drying to nasal passages B. Decrease the client’s oxygen­based respiratory drive Correct C. Increase the risk of pneumonia as a result of drier air passages D. Decrease the client’s carbon dioxide–based respiratory drive Awarded 1.0 points out of 1.0 possible points. 97. 97.ID: 9477045854 A nurse is reading the chest x­ray report of a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse interprets that the tube is positioned above which anatomical area? A. The first tracheal cartilaginous ring B. The point where the larynx connects to the trachea C. The bifurcation of the right and left main stem bronchi Correct D. The area connecting the oropharynx to the laryngopharynx Awarded 1.0 points out of 1.0 possible points. 98. 98.ID: 9477051434 A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume? A. Pulse rate Correct B. Blood pressure C. Pulmonary artery systolic pressure D. Pulmonary artery end­diastolic pressure Awarded 1.0 points out of 1.0 possible points. 99. 99.ID: 9477049128 A nurse is admitting a client with a diagnosis of hypothermia to the hospital. Which signs does the nurse anticipate that this client will exhibit? A. Increased heart rate and increased blood pressure Incorrect B. Increased heart rate and decreased blood pressure C. Decreased heart rate and increased blood pressure D. Decreased heart rate and decreased blood pressure Correct Awarded 0.0 points out of 1.0 possible points. 100. 100.ID: 9477054210 A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client’s neck primarily for which reason? A. It is unnecessary to use both hands B. Feeling dual pulsations may lead to an incorrect measurement C. Palpating both carotid pulses simultaneously could occlude the trachea D. Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop Correct Awarded 1.0 points out of 1.0 possible points. [Show More]

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