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NR341 CJE MED SURG: ADULT HEALTH TEST BANK
WITH 28 0 QUESTIONS AND CORRECT ANSWERS
AND RATIONALES JUST RELEASED THIS YEAR
A nurse is caring for a client who has an electrocardiogram (ECG) showing complete heart block. Which action should the nurse take? A. Request a prescription for intravenous atropine B. Massage the client's carotid arteries one at a time C. Have the client hold their breath and bear down D. Prepare the client for transcutaneous pacing D. Prepare the client for transcutaneous pacing When admitting a client with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the healthcare provider? A. The client's blood pressure is 164/98. B. The client's oxygen saturation is 90%. C. The client appears somnolent. D. The client reports fatigue. C. The client appears somnolent. The nurse admits a terminally ill client to the hospital. What is the first action that the nurse should plan to complete? A. Discuss the normal grief process with the client and family.
B. Determine the client's wishes about end-of-life care. C. Obtain a consult for palliative end-of-life care. D. Emphasize the importance of addressing any family concerns. B. Determine the client's wishes about end-of-life care. The nurse responds to a ventilator alarm to find the client now completely extubated. The client's heart rate is 116 beats per minute, and oxygen saturation is 90%. Which action should the nurse take next? A. Explain to the client what has happened and provide support B. Place the client in high fowlers and suction the clients mouth C. Leave the room and call out for immediate assistance D. Provide supplemental oxygen with the bag-valve-mask (BVM) D. Provide supplemental oxygen with the bag-valve-mask (BVM) A nurse is assessing a client's arterial blood gas results. What finding is expected with hyperventilation? A.Pa02 of 89 B. pH of 7. C. PaHCO3 of 24 D. PaCO2 of 32 D. PaCO2 of 32 A nurse manager of the intensive care unit recognizes the nurses on the unit are experiencing moral distress.Which actions should the nurse manager take to best respond to the moral distress of the nurses? Drag and drop the appropriate responses to the box on the right. Appropriate Responses
A. There are no breath sounds in the left lung and expiratory crackles in the right lung. B. The blood work shows a pH of 7.36 and PaCO2 of 38 C. There is the beginning of a pressure ulcer on the side of the client's mouth. D. The high pressure ventilator alarm goes off every few minutes A. There are no breath sounds in the left lung and expiratory crackles in the right lung. A nurse is caring for a client on mechanical ventilation. The client becomes agitated when trying to communicate their needs. What action should the nurse take? A. Ask the family to leave the room to allow the client to rest. B. Increase the client's level of sedation. C. Provide a white board so the client can write their request. D. Assess the client's RASS score and increase the sedation as prescribed. C. Provide a white board so the client can write their request. A client who is intubated and receiving mechanical ventilation is anxious, restless, and grimacing. Which action should the nurse take first? A. Increase the rate for the ordered propofol infusion B. Sedate the client with the ordered midazolam IV push C. Manually ventilate the client with a bag-valve-mask device D. Try to identify the cause of the distress and provide reassurance D. Try to identify the cause of the distress and provide reassurance Review the electronic health record. For each finding at 0400, indicate whether the implemented interventions by the nurse were: Effective, Ineffective, or Unrelated.
- Effective: Heart rate, BP, The client states. Reports no shortness of breath
- Uneffective: 2+ pitting edema legs and sacrum
- Unrelated: Hypoactive bowel sounds
- Effective: Heart rate, BP, The client states. Reports no shortness of breath
- Uneffective: 2+ pitting edema legs and sacrum
- Unrelated: Hypoactive bowel sounds A nurse is preparing to administer heparin sodium 800 units per hour by continuous intravenous infusion. The pharmacy prepares the medication and delivers the solution labeled heparin sodium 20,000 units per 250 mL in D5W. At what rate will the nurse set the infusion ml/hr?
- 10mL/hr
- 10mL/hr A nurse is caring for a client who is on mechanical ventilation. The client's oxygen saturation has dropped to 85% and the provider is notified. Which action by the interdisciplinary team will best improve the client's oxygenation? A Administering a bronchodilator medication B Increasing the FiO2 setting on the ventilator C Placing the client in Trendelenburg's position D Suctioning the client's endotracheal tube B. Increasing the FiO2 setting on the ventilator The nurse is caring for a client with hemopneumothorax that is being treated with a chest tube. Which observation should the nurse immediately report to the healthcare provider? A. 600 mL of blood in the collection chamber in the last two hours B. Continuous bubbling in the suction-control chamber
D. bag-valve-mask resuscitator E. Chlorhexidine oral care supplies A. Communication board B. Suction equipment D. bag-valve-mask resuscitator E. Chlorhexidine oral care supplies The nurse informs a client that the primary healthcare provider will be arriving at the hospital soon to remove the client's chest tube. In describing the tube removal procedure, which action should the nurse instruct the client to take at the moment the tube is removed? A. Take a deep breath and bear down during tube removal. B. Breathe normally during tube removal. C. Inhale and exhale quickly while the tube is removed. D. Hyperventilate during the removal of the tube. A. Take a deep breath and bear down during tube removal. A nurse is caring for a client with an endotracheal tube. The client is receiving mechanical ventilation and pulls out the endotracheal tube. Which action should the nurse take first? A. Prepare the client for reintubation. B. Elevate the head of the client's bed. C. Assess the client's airway. D. Suction the client's mouth C. Assess the client's airway. Immediately after extubation, the nursing assessment reveals the adult client is coughing and emitting a high-pitched noise when inhaling. What is the priority nursing action?
A. Reassure the client that these symptoms are common and will subside B. Monitor airway and inform the client that reintubation may be necessary C. Instruct the client to limit speaking to decrease vocal cord irritation D. Encourage the client to cough and deep breathe every two hours B. Monitor airway and inform the client that reintubation may be necessary The nurse is caring for a client who has a pneumothorax and is having a chest tube inserted. What action should the nurse take immediately after the chest tube has been inserted? A. Check the client's temperature and urine output B. Check the client's breathing and lung sounds C. Ensure there is a wall suction set up available D. Request a portable chest X-ray to check the tube D. Request a portable chest X-ray to check the tube A nurse enters a client's room and finds the client unresponsive and without a pulse. The client's family member was considering changing the client's status to a do-not-resuscitate (DNR), but the request has not been made, and the healthcare provider has not provided an order for a DNR. What action should the nurse take first? A. Activate the emergency response "code blue" team B. Call the healthcare provider and ask for a DNR order C. Call the client's family member and ask about the request D. Seek immediate help from the charge nurse A. Activate the emergency response "code blue" team
A nurse is caring for a client with the following assessment findings (see exhibit below). What action should the nurse take first? Heart rate 125, RR 29, BP 90/65, Sa02 88% on Non-Rebreather Mask Neuro: Oriented to self only A 500 mL NS fluid bolus B Rapid sequence intubation C Continuous renal replacement D Central line placemen B Rapid sequence intubation A nurse is caring for a client with acute respiratory failure. Which finding(s) should the nurse anticipate? Select all that apply. A Severe dyspnea B Hypertension ?? C Decreased level of consciousness D Nausea E Agitation A. Severe dyspnea B. Hypertension ?? C. Decreased level of consciousness D. Nausea E. Agitation A nurse is caring for a client recovering from surgery three days ago. Upon assessment, the nurse observes that the client is confused, agitated, trying to climb out of bed, and reports seeing non-existent people in the room. Which complication should the nurse suspect the client is experiencing?
A Postoperative delirium B Senile dementia C Polypharmacy D Postoperative infection A. Postoperative delirium A nurse is caring for a client who was recently intubated and placed on mechanical ventilation. Which action (s) should the nurse include in the client's plan of care? Select all the apply. A Implement the ventilator acquired pneumonia (VAP) bundle B Suction the endotracheal tube every hour. C Assess the face for skin breakdown around the tube. D Document the correct position of the endotracheal tube. E Administer prescribed pain medication as needed. A. Implement the ventilator acquired pneumonia (VAP) bundle C. Assess the face for skin breakdown around the tube. D. Document the correct position of the endotracheal tube. E. Administer prescribed pain medication as needed. A client is receiving a continuous infusion of dexedetomidine at 0.6mcq/kg/hr for severe agitation. The nurse would anticipate decreasing the infusion rate for which clinical manifestation (s)? Select all that apply. A Triglyceride level 302 mg/dL B Blood pressure 86/48 mmHg C Heart rate 102 beats per minute
Review the electronic health record. For each assessment finding below, click to specify if the finding is consistent with the disease process of pneumonia or COPD exacerbation. Diminished lung sounds bilaterally Labored breathing Temperature 101.1° F (38.4° C) Sp02 64% on 15 L/min via non-rebreather Heart rate 124 beats per minute Respirations 32 breaths per minute Green thick sputum Diminished lung sounds bilaterally - COPD Labored breathing - Pneumonia, COPD Temperature 101.1° F (38.4° C) - Pneumonia Sp02 64% on 15 L/min via non-rebreather - Pneumonia, COPD Heart rate 124 beats per minute - Pneumonia, COPD Respirations 32 breaths per minute - Pneumonia, COPD Green thick sputum - Pneumonia Review the electronic health record. Complete the following sentence by choosing from the list of options. The client is at highest risk for developing 1. Respiratory Acidosis Respiratory Acidosis Review the electronic health record. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated for the care of the client. Request an order to change the oxygen delivery device: Prepare the client for defibrillation:
Provide oral suctioning as needed : Place the client in the tripod position: Request an order to administer an intravenous fluid bolus: Request an order to administer piperacillin intravenously : Assist the client to perform pursed lip breathing: Request an order for arterial blood gases:
- Request an order to change the oxygen delivery device: Indicated
- Prepare the client for defibrillation: Contraindicated
- Provide oral suctioning as needed : Indicated
- Place the client in the tripod position: Indicated
- Request an order to administer an intravenous fluid bolus: Indicated
- Request an order to administer piperacillin intravenously : Indicated
- Assist the client to perform pursed lip breathing: Indicated
- Request an order for arterial blood gases: Indicated Review the electronic health record. Which 2 healthcare provider orders should the nurse implement first? Select two orders. A. Arterial blood gas (ABG) B. Sputum culture and sensitivity (C&S) C. Azithromycin 500 mg IV every 24 hours D. Comprehensive metabolic panel (CMP) E. Albuterol nebulized every 2 hours PRN for increased difficulty breathing F. Insert an indwelling urethral catheter A. Arterial blood gas (ABG) E. Albuterol nebulized every 2 hours PR A nurse is planning education for a client with a new nitroglycerin prescription who is being discharged after a myocardial infarction and is concerned about resuming sexual activity.
D. Administering nitroglycerin sublingually E. Administering morphine IV push A. Obtaining a 12-lead EKG C. Monitoring continuous pulse oximetry D. Administering nitroglycerin sublingually E. Administering morphine IV push A nurse is caring for a critically ill client who has been intubated and placed on a mechanical ventilator. The client's family wishes that the client not be resuscitated if conditions worsen. The client has not yet been able to make their wishes known as they have not been awake and there are no advanced directives. Which action by the nurse is most appropriate? A. Wait until the client is able to make their wishes known before making any decisions and support the family. B. Explain to the family that it is up to the healthcare provider and team whether to perform or withhold resuscitation efforts. C. Follow the family's wishes and withhold resuscitation efforts if the client's condition worsens. D. Notify the healthcare provider that the family would like to request a do-not-resuscitate (DR) status for the client. D. Notify the healthcare provider that the family would like to request a do-not-resuscitate (DR) status for the client. A nurse provided education for a client with end-stage cancer transitioning to palliative care. Which statement made by the client indicates the need for further education?
A. "It is comforting to know that my spouse will be emotionally supported after I am gone." B. "I am relieved that if I need more pain medication, I will receive it." C. "I am glad my family can stay with me as much as possible." D .The new treatments for my cancer will be available soon so I can stop palliative care." D .The new treatments for my cancer will be available soon so I can stop palliative care." A nurse is caring for a postoperative client. The client has a pleural chest tube connected to suction and a water-seal drainage system. Which should indicate to the nurse that the chest tube is functioning properly? A. Fluctuation of the fluid level within the water seal chamber B. Equal amounts of fluid drainage in each collection chamber C. Absence of fluid in the drainage tubing D. Continuous bubbling within the water seal chamber A. Fluctuation of the fluid level within the water seal chamber A nurse is caring for a client who reports sudden, severe chest pain. What should the nurse do to determine if the client is experiencing a myocardial infarction? A. Perform a 12-lead electrocardiogram (ECG) B. Assess the client's heart and lung sounds C. Request an order for cardiac enzyme studies D. Ask if the pain is is midsternal and severe A. Perform a 12-lead electrocardiogram (ECG) A nurse is caring for a client receiving hospice care for an inoperable brain tumor. When completing an assessment at the end of life, which finding should the nurse expect? A. Muscle flaccidity
A nurse is educating a client following the insertion of a permanent pacemaker. Which information should be included in the educational plan? Select all that apply. A. Handheld metal detectors should not be placed directly over the pacemaker. B. Resume activities that can cause jolting, such as horseback riding, after 4 weeks. C. Do not drive until cleared by the healthcare provider. D. Do not have a microwave oven in the home. E. Count your pulse for 1 minute each morning. A. Handheld metal detectors should not be placed directly over the pacemaker. B. Resume activities that can cause jolting, such as horseback riding, after 4 weeks. C. Do not drive until cleared by the healthcare provider. A nurse is caring for a client that reports pain in the jaw, back, and shoulder. The client also reports shortness of breath and nausea. Which action should the nurse take first? A. Administer an enteric-coated aspirin. B. Obtain an electrocardiogram (ECG). C. Administer morphine. D. Reduce environmental stimulation. B. Obtain an electrocardiogram (ECG) A nurse is caring for a client who reports incisional pain when deep breathing after a coronary artery bypass graft (CABG). Which action should the nurse take next? A. Administer the client's pain medication as prescribed. B. Allow the client to rest before doing deep breathing exercises. C. Obtain a stat 12-lead electrocardiogram (EKG). D. Request the respiratory therapist to instruct the client on deep breathing techniques. A. Administer the client's pain medication as prescribed.
The nurse is assessing a client with a low-pressure ventilator alarm. The nurse is unable to find the cause of the alarm. What is the nurse's priority action? A .Continue to troubleshoot the alarm B. Suction the endotracheal tube using saline C. Call the rapid response team D. Manually ventilate the client D. Manually ventilate the client The nurse is caring for a client who is intubated and mechanically ventilated. The client is restless and coughing, and the client's heart rate has increased. Which action should the nurse take? A. Assess the need for suctioning B. Check the end-tidal CO2 monitor C. Tell the client to relax and stay calm D. Check the client's temperature A. Assess the need for suctioning The nurse is caring for a client diagnosed with ST-segment elevation myocardial infarction (STEMI). The healthcare provider tells the nurse to prepare the client for percutaneous coronary intervention (PCI). Which action should the nurse take next? A. Ask the client about iodine or shellfish allergies B. Prepare to administer alteplase at the bedside C. Place the client on oxygen using a face mask D. Explain the procedure to the client A. Ask the client about iodine or shellfish allergies
