Exam 2 prep NUR 265 LATEST EXAM ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
WITH CORRECT ANSWERS ||\\||\\ ||\\||\\
A client has a new tracheostomy, on a mechanical ventilator
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
with the following settings: SIMV, rate of 12, TV 800, FIo2 80%
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
and PEEP of 5 cmH20. Which assessment finding requires
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
immediate action by the nurse? ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Dry mucous membranes ||\\||\\ ||\\||\\
Rhonchi in upper lobes ||\\||\\ ||\\||\\ ||\\||\\
Blood-tinged sputum ||\\||\\
Constant, nonproductive coughing - correct ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answer✔✔Constant, nonproductive coughing ||\\||\\ ||\\||\\
The nurse notes each time the mechanical ventilator delivers a
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
breath to a client with acute respiratory distress syndrome||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
(ARDS), the peak inspiratory pressure alarm sounds. What is the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
nurse's best intervention?
||\\||\\ ||\\||\\ ||\\||\\
Raise the head of bed to high Fowlers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
,Assess the airway ||\\||\\ ||\\||\\
Suction the client. ||\\||\\ ||\\||\\
Perform chest physiotherapy. - correct answer✔✔Assess the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
airway
A patient with a pleural effusion is scheduled for a
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
thoracentesis. Which action should the nurse take to prepare ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the patient for the procedure?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Position the patient sitting upright on the edge of the bed and ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
leaning forward. ||\\||\\
Start a peripheral IV line to administer the necessary sedative
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
drugs.
Remove the water pitcher and remind the patient not to eat or ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
drink anything for 6 hours. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Obtain a large collection device to hold 2 to 3 liters of pleural
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
fluid at one time. - correct answer✔✔Position the patient
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
sitting upright on the edge of the bed and leaning forward.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
A client with a blood sugar of 525 g/dl and potassium level of
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
6.8 mEq/L exhibits Kussmaul's respiration, confusion, and fruity
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
, breath. Which of the following prescriptions would the nurse ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
anticipate:
3% normal saline IV gtt at 25 mLs/hr
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Sodium bicarbonate infusion and Regular Insulin gtt ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
40 mg Furosemide IVP
||\\||\\ ||\\||\\ ||\\||\\
6L O2 via nasal cannula - correct answer✔✔Sodium
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
bicarbonate infusion and Regular Insulin gtt ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
The nurse palpates the posterior chest while the client says "99"
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
and notes absent fremitus. Which action should the nurse take
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
next?
Encourage the client to turn, cough, and deep breathe. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Palpate the anterior chest and observe for barrel chest. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Review the chest x-ray report for evidence of pneumonia. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Auscultate anterior and posterior breath sounds bilaterally. - ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
correct answer✔✔Auscultate anterior and posterior breath ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
sounds bilaterally. ||\\||\\
WITH CORRECT ANSWERS ||\\||\\ ||\\||\\
A client has a new tracheostomy, on a mechanical ventilator
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
with the following settings: SIMV, rate of 12, TV 800, FIo2 80%
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
and PEEP of 5 cmH20. Which assessment finding requires
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
immediate action by the nurse? ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Dry mucous membranes ||\\||\\ ||\\||\\
Rhonchi in upper lobes ||\\||\\ ||\\||\\ ||\\||\\
Blood-tinged sputum ||\\||\\
Constant, nonproductive coughing - correct ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answer✔✔Constant, nonproductive coughing ||\\||\\ ||\\||\\
The nurse notes each time the mechanical ventilator delivers a
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
breath to a client with acute respiratory distress syndrome||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
(ARDS), the peak inspiratory pressure alarm sounds. What is the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
nurse's best intervention?
||\\||\\ ||\\||\\ ||\\||\\
Raise the head of bed to high Fowlers ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
,Assess the airway ||\\||\\ ||\\||\\
Suction the client. ||\\||\\ ||\\||\\
Perform chest physiotherapy. - correct answer✔✔Assess the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
airway
A patient with a pleural effusion is scheduled for a
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
thoracentesis. Which action should the nurse take to prepare ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
the patient for the procedure?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Position the patient sitting upright on the edge of the bed and ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
leaning forward. ||\\||\\
Start a peripheral IV line to administer the necessary sedative
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
drugs.
Remove the water pitcher and remind the patient not to eat or ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
drink anything for 6 hours. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Obtain a large collection device to hold 2 to 3 liters of pleural
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
fluid at one time. - correct answer✔✔Position the patient
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
sitting upright on the edge of the bed and leaning forward.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
A client with a blood sugar of 525 g/dl and potassium level of
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
6.8 mEq/L exhibits Kussmaul's respiration, confusion, and fruity
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
, breath. Which of the following prescriptions would the nurse ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
anticipate:
3% normal saline IV gtt at 25 mLs/hr
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Sodium bicarbonate infusion and Regular Insulin gtt ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
40 mg Furosemide IVP
||\\||\\ ||\\||\\ ||\\||\\
6L O2 via nasal cannula - correct answer✔✔Sodium
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
bicarbonate infusion and Regular Insulin gtt ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
The nurse palpates the posterior chest while the client says "99"
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
and notes absent fremitus. Which action should the nurse take
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
next?
Encourage the client to turn, cough, and deep breathe. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Palpate the anterior chest and observe for barrel chest. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Review the chest x-ray report for evidence of pneumonia. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Auscultate anterior and posterior breath sounds bilaterally. - ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
correct answer✔✔Auscultate anterior and posterior breath ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
sounds bilaterally. ||\\||\\
