Which action will the nurse include in the plan for care for a client after a bronchoscopy?
1. Following surgery, Mario complains of mild incisional pain while performing deep- breathing and coughing exercises. The nurse’s best response would be:
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2. The nurse needs to carefully assess the complaint of pain of the elderly because older people
3. Mary received AtropineSO4 as a pre-medication 30 minutes ago and is now complaining of dry mouth and her PR is higher, than before the medication was administered. The nurse’s best
4. Ana’s postoperative vital signs are a blood pressure of 80/50 mm Hg, a pulse of 140, and respirations of 32. Suspecting shock, which of the following orders would the nurse question?
5. Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a cystectomy with the creation of an ileal conduit in the morning. He is wringing his hands and pacing the floor when the nurse enters his room. What is the best approach?
6. After surgery, Gina returns from the Post-anesthesia Care Unit (Recovery Room) with a nasogastric tube in place following a gall bladder surgery. She continues to complain of nausea. Which action would the nurse take?
7. Mr. Perez is in continuous pain from cancer that has metastasized to the bone. Pain medication provides little relief and he refuses to move. The nurse should plan to:
8. A client returns from the recovery room at 9AM alert and oriented, with an IV infusing. His pulse is 82, blood pressure is 120/80, respirations are 20, and all are within normal range. At 10 am and at 11 am, his vital signs are stable. At noon, however, his pulse rate is 94, blood pressure is 116/74, and respirations are 24. What nursing action is most appropriate?
9. A 56 year old construction worker is brought to the hospital unconscious after falling from a 2-story building. When assessing the client, the nurse would be most concerned if the assessment revealed:
10. Which of the ff. statements by the client to the nurse indicates a risk factor for CAD?
11. Mr. Braga was ordered Digoxin 0.25 mg. OD. Which is poor knowledge regarding this drug?
12. Valsalva maneuver can result in bradycardia. Which of the following activities will not stimulate Valsalva’s maneuver?
13. The nurse is teaching the patient regarding his permanent artificial pacemaker. Which information given by the nurse shows her knowledge deficit about the artificial cardiac pacemaker?
14. A patient with angina pectoris is being discharged home with nitroglycerine tablets. Which of the following instructions does the nurse include in the teaching?
15. A client with chronic heart failure has been placed on a diet restricted to 2000mg. of sodium per day. The client demonstrates adequate knowledge if behaviors are evident such as not salting food and avoidance of which food?
16. A student nurse is assigned to a client who has a diagnosis of thrombophlebitis. Which action by this team member is most appropriate?
17. A client receiving heparin sodium asks the nurse how the drug works. Which of the following points would the nurse include in the explanation to the client?
18. The nurse is conducting an education session for a group of smokers in a “stop smoking” class. Which finding would the nurse state as a common symptom of lung cancer? :
19. Which is the most relevant knowledge about oxygen administration to a client with COPD?
20. When suctioning mucus from a client’s lungs, which nursing action would be least appropriate?
21. Dr. Santos prescribes oral rifampin (Rimactane) and isoniazid (INH) for a client with a positive Tuberculin skin test. When informing the client of this decision, the nurse knows that the purpose of this choice of treatment is to
22. Mario undergoes a left thoracotomy and a partial pneumonectomy. Chest tubes are inserted, and one-bottle water-seal drainage is instituted in the operating room. In the postanesthesia care unit Mario is placed in Fowler’s position on either his right
23. A client with COPD is being prepared for discharge. The following are relevant instructions to the client regarding the use of an oral inhaler EXCEPT
24. A client is scheduled for a bronchoscopy. When teaching the client what to expect afterward, the nurse’s highest priority of information would be
25. The nurse enters the room of a client with chronic obstructive pulmonary disease. The client’s nasal cannula oxygen is running at a rate of 6 L per minute, the skin color is pink, and the respirations are 9 per minute and shallow. What is the nurse’s best initial action?
26. The nurse is preparing her plan of care for her patient diagnosed with pneumonia. Which is the most appropriate nursing diagnosis for this patient?
27. A nurse at the weight loss clinic assesses a client who has a large abdomen and a rounded face. Which additional assessment finding would lead the nurse to suspect that the client has Cushing’s syndrome rather than obesity?
28. Which statement by the client indicates understanding of the possible side effects of Prednisone therapy?
29. A client, who is suspected of having Pheochromocytoma, complains of sweating, palpitation and headache. Which assessment is essential for the nurse to make first?
30. The nurse is attending a bridal shower for a friend when another guest, who happens to be a diabetic, starts to tremble and complains of dizziness. The next best action for the nurse to take is to:
31. An adult, who is newly diagnosed with Graves disease, asks the nurse, “Why do I need to take Propanolol (Inderal)?” Based on the nurse’s understanding of the medication and Grave’s disease, the best response would be:
32. During the first 24 hours after thyroid surgery, the nurse should include in her care:
33. On discharge, the nurse teaches the patient to observe for signs of surgically induced hypothyroidism. The nurse would know that the patient understands the teaching when she states she should notify the MD if she develops:
34. What is the best reason for the nurse in instructing the client to rotate injection sites for insulin?
35. Which of the following would be inappropriate to include in a diabetic teaching plan?
36. Included in the plan of care for the immediate post-gastroscopy period will be:
37. Which description of pain would be most characteristic of a duodenal ulcer?
38. The client underwent Billroth surgery for gastric ulcer. Post-operatively, the drainage from his NGT is thick and the volume of secretions has dramatically reduced in the last 2 hours and the client feels like vomiting. The most appropriate nursing action is to:
39. After Billroth II Surgery, the client developed dumping syndrome. Which of the following should the nurse exclude in the plan of care?
40. The laboratory of a male patient with Peptic ulcer revealed an elevated titer of Helicobacter pylori. Which of the following statements indicate an understanding of this data?
41. What instructions should the client be given before undergoing a paracentesis?
42. The husband of a client asks the nurse about the protein-restricted diet ordered because of advanced liver disease. What statement by the nurse would best explain the purpose of the diet?
43. Which of the drug of choice for pain controls the patient with acute pancreatitis?
44. Immediately after cholecystectomy, the nursing action that should assume the highest priority is:
45. A Sengstaken-Blakemore tube is inserted in the effort to stop the bleeding esophageal varices in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client complains of difficulty of breathing. The first action of the nurse is to:
46. The client presents with severe rectal bleeding, 16 diarrheal stools a day, severe abdominal pain, tenesmus and dehydration. Because of these symptoms the nurse should be alert for other problems associated with what disease?
47. A client is being evaluated for cancer of the colon. In preparing the client for barium enema, the nurse should:
48. The client has a good understanding of the means to reduce the chances of colon cancer when he states:
49. Days after abdominal surgery, the client’s wound dehisces. The safest nursing intervention when this occurs is to
50. An intravenous pyelogram reveals that Paulo, age 35, has a renal calculus. He is believed to have a small stone that will pass spontaneously. To increase the chance of the stone passing, the nurse would instruct the client to force fluids and to
Which action would the nurse take first when caring for a postoperative client?Which action would the nurse take first when caring for a postoperative client who reports incisional pain? Perform a focused assessment of the client. Which action should the nurse implement to understand the nature of a client's pain?
Which element of nursing care would be implemented after the client has a lumbar puncture procedure?The nurse should note of the following nursing interventions post-lumbar puncture: Apply brief pressure to the puncture site. Pressure will be applied to avoid bleeding, and the site is covered by a small occlusive dressing or band-aid. Place the patient flat on bed.
In which stage of non rapid eye movement sleep does relaxation progress quizlet?Stage 1 of non-rapid eye movement (NREM) sleep is characterized by decreased physiologic activity, beginning with a gradual fall in vital signs and metabolism. Stage 2 of NREM sleep is characterized by a progression of relaxation.
What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?Cilia on the cells of the tissue lining the nasal cavity combined with mucus (from the goblet cells) have a combined role in filtering the air that we breathe. Small particles and germs are trapped in the nasal cavity by the mucus and the cilia works to sweep the mucus out of the passageways.
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