HESI RN ADULT HEALTH 4

HESI RN ADULT HEALTH 4 HESI RN ADULT HEALTH 4 1) A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first? A. Irrigate the nasogastric tube with sterile normalsaline. B. Reposition the client on her side. C. Advance the nasogastric tube 5 cm. D. Administer an intravenous antiemetic as prescribed. B. The priority isto determined if the tube isfunctioning correctly, which would relieve the client's nausea. The least invasive intervention is to reposition the client (B), should be attempted first, followed by (A & C) if these are unsuccessful then (D). 2)When assigning clients on a medical-surgical floor to a RN and a LPN, it is best for the charge nurse to assign which client to the LPN? A. A child with bacterial meningitis with recent seizures. B. An older adult client with pneumonia and viral meningitis. C. A female client in isolation wiht meningococcal meningitis. D. A male client 1 day post-op after drainage of a brain abscess. B. Is the most stable. A, C, D have an increased risk for elevated ICP. 3)Which description ofsymptoms is characteristic of a client with diagnosed with trigeminal neuralgia (tic douloureux)? A. Tinnitus, vertigo, and hearing difficulties. B. Sudden,stabbing, severe pain over the lip and chin. C. Unilateral facial weakness and paralysis. D. Difficulty in talking, chewing, and swallowing. B. Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve. A. Characteristic of Meniere's C. Characteristic of Bell palsey D. Characteristic of disorders of the hypoglossal (12th cranial nerve) 4)Which abnormal lab finding indicatesthat a client with diabetes needsfurther evaluation for diabetic nephropathy? A. Hypokalemia B. Microalbuminauria C. Elevated serum lipids D. Ketonuria B. Microalbuminuria is the earliest sign of nephropathy and indicates the need for follow-up evaluation. Hyperkalemia (A) is associated with end stage renal disease caused by diabetic nephropathy. (C) may be elevated in end stage renal disease. (D) may signal the onset of DKA. 5) An older male client comesto the geriatric screening clinic complaining of pain in hisleft calf. The nurse notices a reddened area on the calf of his right leg that is warm to touch and the nurse suspects that the client may have thrombophlebitis. Which addition assessment is most important for the nurse to perform? A. Measure calf circumference. B. Auscultate the client's breath sounds. C. Observe for ecchymosis and petechiae. D. Obtain the client's blood pressure. B. Since the client may have a pulmonary embolussecondary to the thrombophlebitis. A. Would support the nurses assessment. C. Least helpful since bruising is not associated with thrombophlebitis. D. Less important then auscultation. 6)The nurse know that a client taking diuretics must be assessed for the development of hypokalemia, and that hypokalemia will create changes in the client's normal ECG tracing. Which ECG change would be an expected finding in the client with hypokalemia? A. Tall,spiked T waves B. A prolonged QT interval C. A widening QRS complex D. Presence of a U wave D. A U wave is a positive deflection following the T wave and is often present with hypokalemia. A, B, C indicate hyperkalemia. 7)An older client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which S/SX? A. Leukocytosis and febrile. B. Polycythemia and crackles. C. Pharyngitis and sputum production. D. Confusion and tachycardia. D. The onset of pneumonia is the older may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate. (A, B, C) are often absent in the older with bacterial pneumonia. 8)The nurse observes ventricular fibrillation on telemetry and upon entering the clients bathroom finds the client unconscious on the floor. What intervention should the nurse implement first? A. Administer an antidysrhythmic medication. B. Start cardiopulmonary resuscitation. C. Defibrillate the client at 200 joules. D. Assessthe client's pulse oximetry. B. Ventricular fibrillation is a life-threatening dysrhythmia and CPR should be started immediately. A & C are appropriate but B is the priority. D does not addressthe seriousness of the situation. 9)An older female client with dementia istransferred from a long term care unit to an acute care unit. The client's children express concern that their mother's confusion is worsening. How should the nurse respond? A. "It isto be expected that older people will experience progressive confusion." B. "Confusion in an older person often follows relocation to new surroundings." C. "The dementia is progressing rapidly, but we will do everything we can to keep your mother safe." D. "The acute care staff is not as experienced asthe long-term care staff at dealing with dementia." B. Relocation often results in confusion among older clients and isstressful to clients of all ages. (A) is an inaccurate stereotype. (C) is most likely false there are many factors that cause increased temporary confusion. (D) may be true but does not offer the family a sense ofsecurity about the care. 10) The nurse plansto help an 18-year-old developmentally disabled female client ambulate on the first postoperative day. When the nurse tells her it is time to get out of bed, the client becomes angry and yells at the nurse. "Get out of here! I'll get up when I'm ready." Which response should the nurse provide? A. "Your healthcare provider has prescribed ambulation on the first postoperative day." B. "You must ambulate to avoid serious complicationsthat are much more painful." C. "I know how you feel; you're angry about having to do this, but it is required." D. "I'll be back in 30 minutes to help you get out of bed and walk around the room." D. Returning in 30 minutes provides a cooling off period, is firm, direct, nonthreatening, and avoids argument with the client. B is threatening. C. assumes what the client is feeling. A. avoids the nurse's responsibility to ambulate the client. 11) The nurse is performing hourly neurological check for a client with a head injury. Which new assessment finding warrants the most immediate intervention by the nurse? A. A unilateral pupil that is dilated and nonreactive to light. B. Client cries out when awakened by a verbal stimulus. C. Client demonstrates a loss of memory to the events leading up to the injury. D. Onset of nausea, headache, and vertigo. A. Any changes in pupil size and reactivity is an indication of increasing ICP and should be reported immediately. (B) is normal for being awakened. (C & D) are common manifestations of head injury and less of an immediacy than (A). 12) A male client with arterial peripheral vascular disease (PVD) complains of pain in hisfeet. Which instruction should the nurse give to the UPA to quickly relieve the client's pain? A. Help the client to dangle hislegs. B. Apply compression stockings. C. Assist with passive leg exercises. D. Ambulate three times daily. A. A client who has arterial PVD may benefit from a dependent position which can be achieved by dangling by improving blood flow and relieving pain. (B) is indicated for venousinsufficiency and (C) is indicated for bed rest. (D) is indicated to facilitate collateral circulation and may improve long term complaints of pain. 13) A 58-year-old client, who has no health problems, asks the nurse about taking the pneumococcal vaccine (Pneumovax). Which statement give by the nurse would offer the client accurate information about this vaccine? A. "The vaccine is given annually before the flue season to those over 50 years of age." B. "The immunization is administered once to older adults or persons with a history of chronic illness." C. "The vaccine is for all ages and is given primarily to those person traveling overseasto infected areas." D. "The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years." B. It is usually recommended that persons over 65 years of age and those with a history of chronic illness should receive the vaccine once in a lifetime. (A) the influenza vaccine is given annually. (C) travel is not the main rationale for the vaccine. (D) The vaccine is usually given once in a lifetime. 14)A client with hypertension has been receiving ramipril (Altace) 5 mg PO daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830 the client's blood pressure is 120/70. Which action should the nurse take? A. Administer the dose as prescribed. B. Hold the dose and contact the healthcare provider. C. Hold the dose and recheck the blood pressure in 1 hour. D. Check the healthcare provider's prescription to clarify the dose. A. The BP is WNL and indicates that the medication is working. (B & C) would be indicated if the BP was low (systole below 100). (D) is not required because the dose is within manufacture's recommendations. 15)The nurse know that normal lab values expected for an adult may vary in an older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good overall health. A. Complet blood count revealsincreased WBC and decreased RBC counts. B. Chemistries reveal an increased serum bilirubin with slightly increased liver enzymes. C. Urinalysis revealsslight protein in the urine and bacteriuria with pyuria. D. Serum electrolytesreveal a decreased sodium level with an increased potassium level. C. In older adults the protein found in urine is slightly risen as a result of kidney changes or subclinical UTIs and the client frequently experiences asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying. (A, B, D) are not normal findings. 16) The nurse is completing an admission inter for a client with Parkinson disease. Which question will provide addition information about manifestations the client is likely to experience? A. "Have you ever experienced and paralysis of your arms or legs?" B. " Do you have frequent blackoutspells?" C. "Have you ever been 'frozen' in one spot, unable to move?" D. "Do you have headaches, especially ones with throbbing pain?" C. Parkinson clients frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted, unable to move. (A, B, D) Does not typically occur in Parkinson. 17)During the change of shift report, the charge nurse reviewsthe infusions being received by the clients on the oncology unit. The client receiving which infusion should be seen first? C. Has the highest risk for respiratory depression and therefor should be seen first. (A) Risk of hypotension. (B) Lowest risk. (D) Risk of nephrotoxicity and phlebitis. 18)The home health nurse is assessing a male client being treated for Parkinson disease with levodopa-carbidopa (Sinemet). The nurse observesthat he does not demonstrate any apparent emotions when speaking and rarely blinks. Which intervention should the nurse implement? A. Perform a complete cranial nerve assessment. B. Instruct the client that he may be experiencing medication toxicity. C. Document the presence ofthese assessment findings. D. Advise the client to seek immediate medical evaluation. C. A mask-like expression and infrequent blinking are common clinical features of Parkinsonism. The nurse should document the findings. (A & D) are not necessary. Signs of toxicity (B) are dyskinesia, hallucinations, and psychosis. 19)A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg every 12 hoursIV is prescribed. What is the priority nursing diagnosis for this client? A. Impaired communication related to paralysis ofskeletal muscles. B. Hight risk orinfection related to increased ICP. C. Potential for injury related to impaired lung expansion. D. Social isolation related to inability to communicate. A. To increase the client's tolerance of the endotracheal intubation and/or mechanical ventilation, a skeletal-muscle relaxant such as vecuronium is usually prescribed. (A) is a serious outcome because the client cannot communicate his/her needs. (D) is not as much of a priority. (B) infection is not related to ICP. (C) isincorrect because the ventilator will ensure that the lungs are expanded. 20)The nurse is reviewing the routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question? A. An antianginal with a therapeutic effect of vasodilation. B. An anticholinergic with a side effect of pupillary dilation. C. An antihistamine with a side effect ofsedation. D. A corticosteroid with a side effect of hyperglycemia. B. Clients with angle closure glaucoma should not take medications that dilate the pupil (B) because this can precipitate acute and severely increased intraocular pressure. (A, C, D) do not cause increased intraocular pressure, which is the primary concern. 21)What is the correct location for the placement of the hand for manual chest compressions during CPR on the adult client. A. Just above the xiphoid process on the upper third of the sternum. B. Below the xiphoid process midway between the sternum and the umbilicus. C. Just about the xiphoid process on the lower third of the sternum. D. Below the xiphoid process midway between the sternum and the first rib. Ans: C 22)Twelve hours after chest tube insertion for hemothorax, the nurse notes that the client's drainage has decreased from 50 ml/hr to 5 ml/hr. What is the best inital action for the nurse to take? A. Document this expected decrease in drainage. B. Clamp the chest tube while assessing for air leaks. C. Milk the tube to remove any excessive blood clot build up. D. Assess for kinks or dependent loops in the tubing. D. The least invasive action should be performed to assess the decrease in drainage. (A) is completed after assessing for and problems causing the decreased drainage. (B) is no longer protocol because the increased pressure may be harmful for the client. (C) is an appropriate nursing action after the tube has been assessed for kinks or dependent loops. 23)A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies showed a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with basalskull fracture? A. Bilateral jugular vein distention. B. Oral temperature of 102 degrees F. C. Intermittent focalmotorseizures. D. Intractable pain in the cervical region. B. Increased temp indicates meningitis. (C & D) these symptoms may be exhibited but are not life threatening. (A) JVD is not a typical complication of basal skull fractures. 24)Seconal 0.1 gram PRN at bedtime is prescribed for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A. 1/2 tablet B. 1 tablet C. 1 1/2 tablet D. 2 tablets B. 15 gr = 1 g, 0.1 x 15 = 1.5 grains 25)Which content about self-care should the nurse include in the teaching plan of a client who has genital herpes? (Select all that apply.) A. Encourage annual physical and Pap smear. B. Take antiviral medication as prescribed. C. Use condomsto avoid transmission to others. D. Warm sitz baths may relieve itching. E. Use Nystatin suppositoriesto control itching. F.Douche with weak vinegarsolutions to decrease itching. A,B,C,D. (E) isspecific for Candida infections and (F) is used to treat Trichomonas. 26)A client with chronic asthma is admitted to postanesthesia complaining of pain at level 8 of 10, with a BP of 124/78, pulse of 88 beats/min, and respirations of 20 breaths/min. The postanesthesia recovery prescription is, "Morphine 2 to 4 mg IV push while in recovery for pain level over 5." What intervention should the nurse implement? A. Give the medication as prescribed to decrease the client's pain. B. Call the anesthesia provider for a different medication for pain. C. Use nonpharmacologic techniques before giving the medication. D. Reassess pain level in 30 Minutes and medicate if it remains elevated. B. Call for a different medication because morphine and meperidine (Demerol) have histaminereleasing narcotics and should be avoided when a client has asthma. (A) puts the client at risk for asthma attack. (C & D) disregard the clients prescription and pain relief. 27)During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first? A. Review the client's history for diabetes mellitus. B. Observe the extremity distal to the IV site. C. Monitor the client's serum potassium and blood glucose. D. Evaluate the client's oxygen saturation and breath sounds. C. The client with tumor lysis syndrome may experience hyperkalemia, therefor it is important to monitor serum potassium and blood glucose levels. (A, B, D) are not as priority. 28)During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear upon auscultation, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement? A. Prepare the client for a pericardial tap. B. Administerintravenousfurosemide (Lasix). C. Assist the client to cough and deep breathe. D. Instruct the client to restrict oral fluid intake. A. The client is exhibiting symptoms of cardiac tamponade that results in reduced cardiac output. Treatment is pericardial tap. (B) is not a treatment. (C) is not priority. (D) Fluids are frequently increased but this is not as priority as (A). 29)In assessing an older client with dementia forsundowning syndrome, what assessment technique is best for the nurse to use? A. Observe for tiredness at the end of the day. B. Perform a neurologic exam and mentalstatus exam. C. Monitor for medication side effects. D. Assess for decreased gross motor movement. A. Sundowning syndrome is a pattern of agitated behavior in the evening, believed to be associated with tiredness at the end of the day combined with fewer orienting stimuli, such as activities and interactions. (B, C, & D) with not provide information about this syndrome. 30)Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder? A. Stressincontinence. B. Infection. C. Painless, gross hematuria. D. Peritonitis. B. Infection is the major complication resulting from stasis of urine and subsequent catheterization. (A) is the involuntary loss of urine through an intact urethra as a result of suddenly increased pressure. (C) isthe most common symptom of bladder cancer. (D) isthe most common and serious complication of peritoneal dialysis. 31)The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. What action should the nurse implement first? A. Recommend mental health counseling. B. Review the medications actions and interactions. C. Assessfor the client's daily activity level. D. Provide information regarding a support group. B. Alpha-interferon and ribavirin combination therapy can cause severe depression. (A, B, C) may be implemented after physiological aspect of the situation are assessed. 32)The nurse is assessing a 75-year-old male client forsymptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit? A. Polyuria B. Polydipsia C. Weight loss D. Infection D. S/Sx of hyperglycemia in older adults may include fatigue, infection, and neuropathy (such as sensory changes). (A, B, C) are classic symptoms and may be absent in the older adult. 33)A client who is receiving an ACE inhibitor for hypertension callsthe clinic and reports the recent onset of a cough to the nurse. What action should the nurse implement? A. Advise the client to come to the clinic immediately for further assessment. B. Instruct the client to discontinue use of the drug, and make an appointment at the clinic. C. Suggest that the client lear to accept the cough as a side effect to a necessary prescription. D. Encourage the client to keep taking the drug untilseen by the HCP. D. Cough is a common s/e of ACE inhibitors and is not an indication to discontinue the medication. (A) immediate evaluation is not needed. (B) an antihypertensive should not be stopped abruptly. (C) is demeaning since the cough may be disruptive to the client and other medications may produce results without the s/e. 34)The nurse is observing an unlicensed assistive personnel (UPA) who is performing morning care for a bedfast client with Huntington disease. Which care measure is most important for the nurse to supervise? A. Oral care B. Bathing C. Foot care D. Catheter care A. A client with Huntington disease experiences problems with motor skills such asswallowing and is at high risk for aspiration. (B, C, D) do not pose life-threatening consequences. 35)A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse question as possibly inappropriate for the client? A. Vitamin K1 (AquaMEPHYTON) 5 mg IM daily B. High-calorie, low-sodium diet C. Fluid restriction to 1500 ml/day D. Pentobarbital (Nembutal sodium) 50 mg at bedtime for rest D. Sedatives such as Nembutal are contraindicated for clients with liver damage and can have dangerous consequences. (A) is often prescribed since normal clotting mechanism is damaged. (B) is needed to restore energy. (C) Fluids are restricted to decrease ascites which often accompanies cirrhosis, particularly in later stages of the disease. 36)A client diagnosed with chronic kidney disease (CDK) 2 years ago is regularly treated at a community hemodialysisfacility. In assessing the client before hisscheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A. Hypophosphatemia B. Hypocalcemia C. Hyponatremia D. Hypokalemia B. Hypocalcemia develops in CKD due to chronic hyperphosphatemia not (A). (C & D) incorrect you would find hypernatremia and hyperkalemia 37)Debilitating anginal pain can be decreased in some clients by the administration of betablocking agents such as nadolol (Corgard). Which client requires the nurse to use extreme caution when administering Corgard? A. A 56-year-old air traffic controller who had bypasssurgery 2 years ago. B. A 47-year-old kindergarten teacher diagnosed with asthma 40 years ago C. A 52-year-old unemployed stock broker who refusestreatment for alcoholism D. A 60-year-old retired librarian who takes a diuretic daily for hypertension. B. asthma must be carefully monitored because beta blockers because it can induce cardiogenic shock and reduce bronchodilation efforts. (A & D) this medication is indicated and (C) it is not contraindicated. 38)A male client who has never smoked but has had COPD for the past 5 years is now being assessed for cancer of the lung. The nurse knowsthat he is most likely to develop which type of lung cancer? A. Adenocarcinoma B. Oat-cell carcinoma C. Malignant melanoma D. Squamous-cell carcinoma A. is the only lung cancer not related to cigarette smoking related to lung scarring and fibrosis from preexisting pulmonary diseases such as TB and COPD. (B& D) are related to smoking. (C) is a skin cancer 39)The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the healthcare provider before the chest tube is removed? A. Tidal of water in the waterseal chamber B. Bilateral muffled breath sounds at bases C. Temperature of 101 degrees F D. Absence of chest tube drainage for 2 days. A. Tidal in the water seal chamber should be reported to the HPC to show that the chest tube is working properly. (B) may indicate hypoventilation from the chest tube and usually improves when the tube is removed. (C) indicates infection (D) is an expected finding. 40)A central venous catheter has been inserted via a jugular vein and a radiography has confirmed placement of the catheter. A prescription has been received forstat medication but IV fluids have not yet been started. What action should the nurse take prior to administering the prescribed medication? A. Assessforsigns of jugular vein distention. B. Obtain the needed intravenous solution. C. Administer a bolus of normalsaline solution. D. Flush the line with heparinized saline. C. A medication can be administered central line without IV fluids, flush with normal saline to remove heparin that may counteract with the medication. (B) is used following the medication and a second saline bolus. (A) will not impact the the med administration and is not a priority. (B) Administration of the stat medication is more of a priority than (B). 41)The nurse assesses a postoperative client. Oxygen is being administered at 2 L/min and a saline lock is in place. Assessment shows cool, pale, moist skin. The client is very restless and has scant urine in the urinary drainage bag. What intervention should the nurse implement first. A. Measure urine specific gravity. B. Obtain IV fluids for infusion protocol. C. Prepare for insertion of a central venous catheter. D. Auscultate the client's breath sounds. B. The client is at risk for hypovolemic shock and is exhibiting early signs. Start IV to restore tissue perfusion. (A, C, D) are all important but less of a priority. 42)A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first? A. Support the client to a sitting position. B. Ask the client to walk slowly back to the room. C. Administer a sublingual nitroglycerin tablet. D. Provide oxygen via nasal cannula. A. Assist in safely repositioning and then administer (C & D). Then the client can be escorted back to the room via wheelchair or stretcher (B). 43)A 55-year-old male client is admitted to the coronary care unit having suffered an acute myocardial infarction (MI). Within 24 hours of the occurrence, the nurse can expect to find which systemic sign? A. Elevated serum amylase level B. Elevated CM-MB level C. Prolonged prothrombin time (PT) D. Elevated serum BUN and creatinine B. Tissue damage in the myocardium causes the release of cardiac enzymes into the blood system. An elevated CM-MB is a recognized indicator of an MI. It peaks 12 - 24 hours and returns to normal within 48 - 78 hours. (A) would indicate pancreatitis or a gastric disorder. (D) Although an elevated BUN might be related to an acute MI it is usually associated with dehydration, high protein intake or gastrointestinal bleeding and creatine levels indicate renal damage. (C) Indicates effective anticoagulation therapy. 44)The nurse is assessing a client who presents with jaundice. Which assessment finding is the most significant indication that further follow up is needed? A. Urine specific gravity of 1.03 with a urine output of 500 ml in 8 hours B. Frothy,tea-colored urine C. Clay-colored stools and complaints of pruritus D. Serum amylase and lipase levelsthat are twice their normal levels D. Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and an elevated serum amylase and lipase indicate pancreatic injury. (A) is a normal finding. (B & C) are expected findings for jaundice. 45)A client with cirrhosis states that his disease was cause by a blood transfusion. What information should the nurse obtain first to provide effective client teaching? A. The year the blood transfusion was received B. The amount of alcohol the client drinks C. How long the client has had cirrhosis D. The client's normal coping mechanisms A. The nurse should first verify the clients explanation (A) since it may be accurate due to prior to 1990 blood was not screened for Hep C and hep C can cause cirrhosis. Not all cirrhosis is caused is caused by alcoholism (B) (C & D) provide useful but less relevant information. 46)What isthe correct procedure for performing an ophthalmoscopic examination on a client's right eye? A. Instruct the client to look at the examiner's nose and not move his/her eyes during the exam. B. Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye. C. From a distance of 8 to 12 inches and slightly to the side, shine the light into the client's pupil. D. For optimum visualization, keep the ophthalmoscope at least 3 inchesfor the client's eye C. The client should focus on a distant object in order to promote pupil dilation. The ophthalmoscope should be set on the 0 lensto begin (creates no correction) and should be held in front of the examiner's left eye when examining the client's right eye and kept 1" from the client's eye for optimum visualization. (A, B, D) are incorrect procedures. 47)The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What assessment data should the nurse collect immediately? A. Reactivity of deep tendon reflexes, comparing upper to lower extremities. B. Vital signs readings, excluding blood pressure if need equipment is unavailable. C. Memory of eventsthat occurred before and after the blow to the head. D. Ability to spontaneously open the eyes before any tactile stimuli are given. D. The LOC should be immediately established immediately after the head injury has occurred. Spontaneous eye opening (D) is a simple measure of LOC. (A) is not the best indicator of LOC. (B) is important but not the best indicator of LOC. (C) can be assessed after LOC has been established by assessing eye opening. 48)A 43-year-old homeless, malnourished female client with a history of alcoholism is transferred to the ICU. She is placed on telemetry, and the rhythm strip shown is obtained. The nurse palpates a heart rate of 160 beats/min, and the client's blood pressure is 90/54. Based on these finding, which IV medication should the nurse administer? A. Amiodarone (Cordarone) B. Magnesium sulfate C. Lidocaine (Xylocaine) D. Procainamide (Pronestyl) B. Because the client has chronic alcoholism, she is likely to have hypomagnesium. (B) is the recommended drug for torsades de pointes (AHA, 2005), which is a form of polymorphic ventricular tachycardia (VT), usually associated with a prolonged QT interval that occurs with hypomagnesemia. (A and D) increase the QT interval, which can cause the torsades to worsen. (C) is the antiarrhythmic of choice in most cases of drug-induced monomorphic VT, not torsades. 49)The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit are decreased. What additional change in lab data should the nurse expect? A. Increased serum albumin B. Decreased serum creatinine C. Decreased serum ammonia D. Increased liver function tests C. The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increases the ammonia levels in the clients with advanced liver disease,so removal of blood, a protein source, from the intestines resultsin reduced ammonia. (A, B, D) will not be significantly impacted by the removal of blood. 50)A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique? A. Turns on the continuous wallsuction to -190 mm Hg B. Insertsthe catheter until resistance or coughing occurs C. Withdrawsthe catheter while maintaining suctioning D. Re-clearsthe tracheostomy aftersuctioning the mouth B. indicates correct technique for performing suctioning. Suction pressure should be between -80 and -120 (A). The catheter should be withdrawn 1-2 cm at a time with intermittent suction (C). (D) introduces pathogens. 51)The nurse is planning the care for a client who is admitted with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which interventionsshould the nurse include in this client's plan of care? (Select all that apply.) A. Salt-free diet B. Quiet environment C. Deep tendon reflex assessments D. Neurologic checks E. Daily weights F.Unrestricted intake of free water B, C, D, E. SIADH results in water retention and dilutional hyponatremia, which causes neurologic change when serum sodium levels are less than 115 mEq/L. The nurse should maintain a quiet environment (B) to prevent overstimulation that can lead to periods of disorientation, assess deep tendon reflexes(C) and neurologic checks(D) to monitor for neurologic deterioration. Daily weights (E) should be monitored to assess for fluid overload: 1 kg weight gain equals 1 L of fluid retention, which further dilutes serum sodium levels. (A and F) contribute to dilutional hyponatremia. 52)levodopa (Sinemet) Parkinsons Disease lessen tremors increases amount of levodopa to CNS (dopamine to the brain) s/stoxicity=dyskinesia, hallucinations, psychosis 53)Aldosteronism lab =decreased serum level of potassium hypokalemia hypertension 54)seconel sleep aide 15g=1g 55)Laryngectomy cuffshould be inflated only prior to feeding 56)tumor lysis syndrome hyperkalemia may occur =requiresinsulin to reduce serum potassium = monitorserium potassium and blood glucose levels 57) older adults protein found in urine slightly rises as a result of kidney change or UTI w/asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying 58) chest tube decreased drainage =assess for kinks or dependant loops -do not clamp off 59)angina pectoris when walking=t to seated position; ngual nitroglycerin; n 4. wheelchairto room 60) SIADH inappropriate antidiuretic hormone secreation water retention & dilutional hyponatremia POC=quiet enviroment, deep tendon reflex assessment, neurologic checks, daily weights 1kg=1L 61) methotrexate (Mexate) immunosuppressant can cause bone marrow depression rheumatoid arthritis lab=hemaglobin decrease =adverse side effect 62)pentobarbital (Neubatal sodium) contriandicated with liver damage 63)cirrhosis Vitamin K1 (AquaMephyton) high calorie, low sodium diet sodium restriction w/ edema fluidsrestricted to decrease ascites late stage = ascites 64)TPN total protein nutrition only regular insulin is adm. IV return containing NPH 65)kidney stone strain all urine most important encourage urine 66)blunt trama to back of head LOC assessment most important 67)cancer reduce fats increase fruits, vegetables and fiber ie bran flakes,skim milk, orange slices 68)telemetry ventrical fibrillation = life threatening start CPR 69)COPD contributing factor=smoking 70)osteoporosis most common cause of fractured hip= reduced calcium in bones result of hormonal changes during perimenaopausal years 71)esophagogastromy esophageal cancer risk for infection = meticulious oral care should be provided several times a day prior to surgery 72)diverticulitits hard ridgid abdomen & elevated WBC = peritonitis = medical emergency should be reported to PCP immediately s/sleft lower quadrant pain; elevated temperature; refusing to eat; nausea 73)lactulose (Cephulac) reduce blood ammonia by excreation of ammonia by stools 2 -3 soft stools per day 74)IV'sinfusions potential problems morphine, continous epidural = respiratory depression magnesium continous infusion = hypotension vancomycin intermittent infusion = nephrotoxicity& phlebitits 75)pancreatitis serium amylase & lipase 2 to 5 times higher than normal hypercalcemia 40 ~ 75% = positive trousseau sign = carpalspasm severe boring pain 76)hypercalcemia positive trousseau sign = carpalspasm 77)neurogenic bladder infection - from stasis of urine and subsuquent catheterization 78) CKD chronic kidney disease prior to hemodialysislab= hypocalcemia due to hyperphosphatemia, hyperkalemic & hypernatremic 79) gangrene necrosis/tissue death priority prevent infection 80)olpthalmoscopic exam from a distance of 8-12 inches and slightly to the side,shine the light in the clients pupil; client should focus on distant object to promote dialation, olpthalmoscopic set at 0 lensto begin, should be held in front of the examiners left eye when examining clients right eye and kept within 1 inch of clients eye for optimum visualation 81) hypokalemia patients on diuretics will change patients normal ECG = U wave is positive deflection following the T wave often present in hypokalemia 82) ECG U wave is positive deflectionfollowing the T wave often present in hypokalemia tallspiked T wave, prolonged QT intervial, widening QRS complex are allsigns of hyperkalemia 83)Hyperkalemia ECG=tallspiked T wave, prolonged QT intervial, widening QRS complex are allsigns of hyperkalemia; tumorlysissyndrome 84)ACE inhibitor cough os a common side effect hypertension do notstop abruptly (rebound hypertension may occur) 85)permanent pacemaker changes in pulse rate in rythem may indicate pacer failure dizziness may be due to decreased heart rate leading to decreased cardiac output; should carry a card in wallet with type and serial number of pacemaker; report redness and tenderness -s/s infection 86)sundowning agitated behavior in the evening observe for tiredness at the end of the day 87)Pap smear should be continued through menapause to test for vaginal and cervical cancer 88)NG Tube no drainage in 2 hours client nausated = reposition client on side 89)hypomagnesemia chronic alcholic ie HR 160 BP 90/54 give IV magnesium sulphate prolonged QT intervial 90) Magnesium Sulphate hypomagnesemia reccomended fortorsadesde pointes a form of polymorphic ventrical tackycardia associated with a prolonged QT intervial that occurs with hypomagnesemia 91) older adults stooped posture resultsin upper torso becomming center of gravity 92)Cushing Syndrome resultsfrom hypersecreation glucocorticoidsin the adrenal cortex often develope diabetes mellitus - monitor serum glucose levels generialized edema low calorie, low carbohydrate, low sodium diet 93)jaundice serium amylase & lipase 2 times higher than normal indicate pancreatic injury frothy tea colored urine clay colored stools complaints of puritis 94) PVD peripheral vascular disease help client dangle legs 95) digitalis (Lanoxin) digoxin cardiac glycoside can build up toxic levels s/s anexoria, nausea, vomiting, diarrhea, headache, fatigue 96)Hepatitis B health care providersshould have Hep B vaccine; transmitted by fecal/oral contamination 97)nadolol (Corgard) beta blocker dibilatating anginal pain bypasssurgery patients use with diuretic for hypertension use extreme caution with respiratory problems(asthma) and congestive heart failure 98)CPR just above the xiphoid process on the lower third of the sternum 99)trigeminal neuralgia (5th crainal nerve) sudden stabbing severe pain over the lip and chin 100)meniere syndrome (8th crainal nerve) tinnitus, vertigo, eharing difficulties 101)Bell palsy (7th crainal nerve) unilateral facial weakness and paralysis 102)Hypoglossal (12th crainal nerve) difficulty chewing, talking and swallowing 103)TSS Staphlococcus aures produce a toxin that can enter the blood stream through vaginal mucosa. wash hands before and change tampon frequently 4-6 hours 104) small bowel obstruction peritonis w/ Temperature of 102 notify HCP immediately abdominal cramping 105) vecuronium bromide (Norcuron) skeletal muscle relaxatant ND: impaired communication R/T paralysis ofskeletalmuscles 106)neuro function altered neuro function = 107)Amniocentesis Surgical puncture to remove fluid from the sac around the embryo. 108)Tonsillitis Inflammation of lymph tissue in the throat. 109)-ptosis Prolapse 110)Ischemia Blood is held back from an area. 111)Necr/o Death 112)Acromegaly Enlargement of extremities after puberty due to pituitary gland problem. 113)Otalgia Pain in the ear. 114)Chronic Continuing over a long period of time. 115)Arteriole Small artery. 116)-scope Instrument to visually examine. 117)Cystocele Hernia ofthe urinary bladder. 118)Malignant myeloma Tumor of bone marrow. 119)Myelogram X-ray record ofthe spinal cord. 120)-cocci Berry shaped bacteria. 121)-graph Instrument to record. 122)-oid Resembling 123)Leukocyte Eosinophil is a (an) 124)Laryngectomy Removal of the voice box. 125)Angioplasty Surgical repair of blood vessel. 126)Lymphocyte A blood cell that produces antibodies. 127)Hypertrophy Excessive devolopment. 128)-therapy Treatment. 129)-stomy Surgical creation of a permanent opening to the outside of the body. 130)Catabolism The process by which food is burned to realease energy. 154) The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting: A. Chest excursion B. Spinal curvatures C. The respiratory pattern D. The fingernail and its base D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger. 155) The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood gases to be drawn. Which of the following is the minimum length of time the nurse should plan to hold pressure on the puncture site? A. 2 minutes B. 5 minutes C. 10 minutes D. 15 minutes B. 5 minutes Following obtaining an arterial blood gas, the nurse should hold pressure on the puncture site for 5 minutes by the clock to be sure that bleeding hasstopped. An artery is an elastic vessel under higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient. 156) The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. The nurse should: A. test the drainage for the presence of glucose. B. suction the nose to maintain airway clearance. C. document the findings and continue monitoring. D. apply a drip pad and reassure the patient this is normal. A. test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF. 157)When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priority assessment would be: A. Airway patency B. Patient comfort C. Incisional drainage D. Blood pressure and heart rate A. Airway patency Remember ABCs with prioritization. Airway patency is always the highest priority and is essential for a patient undergoing surgery surrounding the upper respiratory system. 158) When initially teaching a patient the supraglottic swallow following a radical neck dissection, with which of the following foods should the nurse begin? A. Cola B. Applesauce C. French fries D. White grape juice A. ColaWhen learning the supraglottic swallow, it may be helpful to start with carbonated beverages because the effervescence provides clues about the liquid's position. Thin, watery fluidsshould be avoided because they are difficult to swallow and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce, would decrease the risk of aspiration, but carbonated beverages are the better choice to start with. 159) The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of 20. Which of the following nursing diagnosisis most appropriate based upon this assessment? A. Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C. Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick secretions A. Hyperthermia related to infectious illness Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths per minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum. 160) Which of the following physical assessment findings in a patient with pneumonia best supportsthe nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85% B. Respiratory rate of 28 C. Presence of greenish sputum D. Basilar crackles D. Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation ofsecretionsin the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. 161) Which of the following clinical manifestations would the nurse expect to find during assessment of a patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion B. Fine crackles in all lobes on auscultation C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes C. Increased vocal fremitus on palpation. A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include dullness to percussion, bronchial breath sounds, and crackles in the affected area. 162) Which of the following nursing interventions is of the highest priority in helping a patient expectorate thick secretions related to pneumonia? A. Humidify the oxygen as able B. Increase fluid intake to 3L/day if tolerated. C. Administer cough suppressant q4hr. D. Teach patient to splint the affected area. B. Increase fluid intake to 3L/day if tolerated. Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful, but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful, but does not liquefy the secretions so that they can be removed. 163) During discharge teaching for a 65-year-old patient with emphysema and pneumonia, which of the following vaccines should the nurse recommend the patient receive? A. S. aureus B. H. influenzae C. Pneumococcal D. Bacille Calmette-Guérin (BCG) C. Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility. 164) The nurse evaluatesthat discharge teaching for a patient hospitalized with pneumonia has been most effective when the patient states which of the following measures to prevent a relapse? A. "I will increase my food intake to 2400 calories a day to keep my immune system well." B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to reevaluate." C. "I willseek immediate medical treatment for any upper respiratory infections." D. "Ishould continue to do deep-breathing and coughing exercises for at least 6 weeks." D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." It is important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks until all of the infection has cleared from the lungs. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. Increased fluid intake, not caloric intake, isrequired to liquefy secretions. Home O2 is not a requirement unless the patient's oxygenation saturation is below normal. 165) After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that which of the following physician orders have been completed before administering a dose of cefotetan (Cefotan) to the patient? A. Serum laboratory studies ordered for AM B. Pulmonary function evaluation C. Orthostatic blood pressures D. Sputum culture and sensitivity D. Sputum culture and sensitivityThe nurse should ensure that the sputum for culture and sensitivity wassent to the laboratory before administering the cefotetan. It isimportant that the organisms are correctly identified (by the culture) before their numbers are affected by the antibiotic; the test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, all of the other options will not be affected by the administration of antibiotics. 166) Which of the following nursing interventions is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease? A. Positioning patient on rightside. B. Maintaining adequate fluid intake C. Performing postural drainage every 4 hours D. Positioning patient with "good lung down" D. Positioning patient with "good lung down" Therapeutic positioning identifiesthe best position forthe patient assuring stable oxygenation status. Research indicatesthat positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation. 167) A 71-year-old patient is admitted with acute respiratory distressrelated to cor pulmonale. Which of the following nursing interventions is most appropriate during admission of this patient? A. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. B. Perform a comprehensive health history with the patient to review prior respiratory problems. C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. D. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed once the patient's acute respiratory distress is being managed. 168) When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses because of impairment of which of the following? A. Reflex bronchoconstriction B. Ability to filter particles from the air C. Cough reflex D. Mucociliary clearance D. Mucociliary clearance Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions, chronic cough, and frequent respiratory infections. 169) While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which of the following nursing interventions is most appropriate based upon these findings? A. Continue with ambulation as this is a normal response to activity. B. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity. C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. D. Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. An oxygen saturation level that drops below 90% with activity indicatesthat the patient is not tolerating the exercise and needs to have supplemental oxygen applied. 170) The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen saturation 91% on room air. Which of the following should the nurse first suspect as the etiology of this episode? A. Septic embolus from the knee joint B. Pulmonary embolus from deep vein thrombosis C. New onset of angina pectoris D. Pleural effusion related to positioning in the operating room B. Pulmonary embolus from deep vein thrombosis The patient presents the classic symptoms of pulmonary embolus: acute onset ofsymptoms, tachypnea, shortness of breath, and chest pain. 171) In the case of pulmonary embolusfrom deep vein thrombosis, which of the following actions should the nurse take first? A. Notify the physician. B. Administer a nitroglycerin tablet sublingually. C. Conduct a thorough assessment of the chest pain. D. Sit the patient up in bed astolerated and apply oxygen. D. Sit the patient up in bed as tolerated and apply oxygen.The patient's clinical picture is consistent with pulmonary embolus, and the first action the nurse takes should be to assist the patient. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician. 172) The nurse is caring for a postoperative patient with sudden onset of respiratory distress. The physician orders a STAT ventilation-perfusion scan. Which of the following explanations should the nurse provide to the patient about the procedure? A. Thistest involves injection of a radioisotope to outline the blood vessels in the lungs, followed by inhalation of a radioisotope gas. B. Thistest will use special technology to examine cross sections of the chest with use of a contrast dye. C. This test will use magnetic fields to produce images of the lungs and chest. D. This test involves injecting contrast dye into a blood vessel to outline the blood vessels of the lungs. A. Thistest involves injection of a radioisotope to outline the blood vessels in the lungs, followed by inhalation of a radioisotope gas.A ventilation-perfusion scan has two parts. In the perfusion portion, a radioisotope is injected into the blood and the pulmonary vasculature is outlined. In the ventilation part, the patient inhales a radioactive gas that outlines the alveoli. 173) During assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to which of the following pathophysiologic changes? A. Laryngospasm B. Overdistention of the alveoli C. Narrowing of the airway D. Pulmonary edema C. Narrowing of the airwayNarrowing of the airway leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing. 174) A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which of the following clinical manifestations might be present as an early symptom during an exacerbation of asthma? A. Anxiety B. Cyanosis C. Hypercapnia D. Bradycardia A. Anxiety An early symptom during an asthma attack is anxiety because he is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating. 175) The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. Which of the following is the primary reason for the nurse to carefully inspect the chest wall of this patient? A. Observe forsigns of diaphoresis B. Allow time to calm the patient C. Monitor the patient for bilateral chest expansion D. Evaluate the use of intercostal muscles D. Evaluate the use of intercostal muscles The nurse physically inspectsthe chest wall to evaluate the use of intercostal (accessory) muscles, which gives an indication of the degree of respiratory distress experienced by the patient. 176) Which of the following positionsis most appropriate for the nurse to place a patient experiencing an asthma exacerbation? A. Supine B. Lithotomy C. High-Fowler's D. Reverse Trendelenburg C. High-Fowler'sThe patient experiencing an asthma attack should be placed in high-Fowler's position to allow for optimal chest expansion and enlist the aid of gravity during inspiration. 177) The nurse is caring for a patient with an acute exacerbation of asthma. Following initial treatment, which of the following findings indicatesto the nurse that the patient'srespiratory status is improving? A. Wheezing becomes louder B. Vesicular breath sounds decrease C. Aerosol bronchodilatorsstimulate coughing D. The cough remains nonproductive A. Wheezing becomes louder The primary problem during an exacerbation of asthma is narrowing of the airway and subsequent diminished air exchange. Asthe airways begin to dilate, wheezing gets louder because of better air exchange. 178) The nurse identifiesthe nursing diagnosis of activity intolerance for a patient with asthma. The nurse assesses for which of the following etiologic factor for this nursing diagnosis in patients with asthma? A. Anxiety and restlessness B. Effects of medications C. Fear ofsuffocation D. Work of breathing D. Work of breathingWhen the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations,they use all available energy to breathe and have little left over for purposeful activity. 179) The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate which of the following is likely to be the next step in treatment? A. Pulmonary function testing B. Systemic corticosteroids C. Biofeedback therapy D. Intravenousfluids B. Systemic corticosteroids Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initialresponse to the β-adrenergic bronchodilator is insufficient. 180)A patient with acute exacerbation of COPD needsto receive precise amounts of oxygen. Which of the following types of equipment should the nurse prepare to use? A. Venturi mask B. Partial non-rebreather mask C. Oxygen tent D. Nasal cannula A. Venturi mask The Venturi mask delivers precise concentrations of oxygen and should be selected whenever this is a priority concern. The other methods are less precise in terms of amount of oxygen delivered. 181) While teaching a patient with asthma about the appropriate use of a peak flow meter, the nurse instructs the patient to do which of the following? A. Use the flow meter each morning after taking medications to evaluate their effectiveness. B. Empty the lungs and then inhale quickly through the mouthpiece to measure how fast air can be inhaled. C. Keep a record of the peak flow meter numbers ifsymptoms of asthma are getting worse. D. Increase the doses of the long-term control medication if the peak flow numbers decrease. C. Keep a record of the peak flow meter numbers if symptoms of asthma are getting worse. It is important to keep track of peak flow readings daily and when the patient'ssymptoms are getting worse. The patient should have specific directions as to when to call the physician based on personal peak flow numbers. Peak flow is measured by exhaling into the meters and should be assessed before and after medications to evaluate their effectiveness. 182) The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, the nurse should provide which of the following instructions? A. "Close lipstightly around the mouthpiece and breathe in deeply and quickly." B. "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." C. "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible." D. "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." A. "Close lips tightly around the mouthpiece and breathe in deeply and quickly." Dry powder inhalers do not require spacer devices. The patient should be instructed to breathe in deeply and quickly to ensure medicine moves down deeply into lungs. The patient may not taste or sense the medicine going into the lungs. 183) The nurse determinesthat a patient is experiencing common adverse effectsfrom the inhaled corticosteroid beclomethasone (Beclovent) after noting which of the following? A. Adrenocortical dysfunction and hyperglycemia B. Elevation of blood glucose and calcium levels C. Oropharyngeal candidiasis and hoarseness D. Hypertension and pulmonary edema C. Oropharyngeal candidiasis and hoarseness Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose. 184) The nurse determinesthatthe patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state which of the following as the primary benefit? A. "Now I will not need to breathe in as deeply when taking the inhaler medications." B. "This device will make itso much easier and faster to take my inhaled medications." C. "I will pay lessfor medication because it will last longer." D. "More of the medication will get down into my lungs to help my breathing." D. "More of the medication will get down into my lungs to help my breathing." A spacer assists more medication to reach the lungs, with less being deposited in the mouth and the back of the throat. 185) Which of the following test results identify that a patient with an asthma attack is responding to treatment? A. A decreased exhaled nitric oxide B. An increase in CO2 levels C. A decrease in white blood cell count D. An increase in serum bicarbonate levels A. A decreased exhaled nitric oxide. Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma. 186) The nurse determinesthat the patient is not experiencing adverse effects of albuterol (Proventil) after noting which of the following patient vital signs? A. Oxygen saturation 96% B. Respiratory rate of 18 C. Temperature of 98.4° F D. Pulse rate of 76 D. Pulse rate of 76 Albuterol is a β2-agonist that can sometimes cause adverse cardiovascular effects. These would include tachycardia and angina. A pulse rate of 76 indicatesthat the patient did not experience tachycardia as an adverse effect. 187) The patient has an order for each of the following inhalers. Which of the following should the nurse offer to the patient at the onset of an asthma attack? A. Albuterol (Proventil) B. Beclomethasone (Beclovent) C. Ipratropium bromide (Atrovent) D. Salmeterol (Serevent) A. Albuterol (Proventil) Albuterol is a short-acting