PT 5

50問 • 1年前

問題一覧

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority?

Educating the client on adherence to the treatment regimen

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)?

Provide oral care every 4 hours.

The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met?

Antibiotics started before admission

A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective?

"I will take this medication on an empty stomach."

A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a few days ago and shows the nurse the results of what the client calls an allergy test, as shown below: What action by the nurse takes priority?

Immediately place the client on Airborne Precautions.

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.)

22-year-old client with asthma, Client who is taking medication for hypertension, Healthy 72-year-old client, Client with well-controlled diabetes

A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.)

Assisting with chest tube insertion, Facilitating pleural fluid sampling, Performing frequent respiratory assessment, Providing antipyretics as needed

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?

Notify the Rapid Response Team.

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate?

Teach the client about factor V Leiden testing.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best?

"The blood clot interferes with perfusion in the lungs."

A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?

Increase the heparin rate.

A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best?

Prepare preoperative teaching for an inferior vena cava (IVC) filter.

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?

Platelet count: 82,000/L

An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority?

Listen to the client's lung sounds.

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?

The upper peak airway pressure limit alarm is on.

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?

Large chefs salad and muffin

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?

strict vegetarian

A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?

Choosing an 18-gauge, 2-inch needle

A client in the emergency department has several broken ribs. What care measure will best promote comfort?

Allowing the client to choose the position in bed

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?

Alteplase (Activase)

A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: What action by the nurse is most appropriate?

Facilitate a STAT pulmonary angiography.

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)

Client with a new spinal cord injury on a rotating bed, Older client who is 1-day post hip replacement surgery, Young obese client with a fractured femur

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)

Exercise on a regular basis., Maintain a healthy weight., Stop smoking cigarettes.

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)

Acknowledge the frightening nature of the illness, Give simple explanations of what is happening., Stay with the client and speak in a quiet, calm voice., Delegate a back rub to the unlicensed assistive personnel (UAP)

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)

Adherence to proper hand hygiene, Administering anti-ulcer medication, Elevating the head of the bed, Providing oral care per protocol

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)

Allow visitors at the clients bedside, Ensure the client can communicate if awake, Provide back and hand massages when turning, Turn the client every two hours or more

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)

Chest wall stiffness, Decreased muscle strength, Less lung elasticity

A nurse is caring for a patient with asthma and assesses signs and symptoms of inadequate oxygenation. Which intervention is the most appropriate?

increase fluid intake

What is a characteristic of chronic obstructive pulmonary disease that places a patient at risk for poor nutrition?

Excessive respiratory effort

Which nursing intervention enhances the nutritional status of a patient with COPD?

offer small and frequent meals

Which walking program would be the most effective for the nurse to recommend as part of a progressive walking program for an obese patient with COPD?

10 to 15 minutes a day

What is the result of status asthmaticus that is not corrected?

Pneumothorax, severe hypoxemia, and respiratory arrest

What should a nurse focus on when assessing for major sources of infection in a patient with COPD?

Stasis of respiratory secretions

A young patient with acquired immunodeficiency syndrome (AIDS) reports debilitating night sweats. Why should the home health nurse suggest that the patient visit the clinic?

Tuberculosis (TB) screening

A nurse is caring for an 80-year-old patient with COPD and suspects right-sided heart failure after assessing and recording the data. What should decrease with right-sided heart failure?

urine output

A patient with TB asks the nurse how long he will have to take his TB medications. What is the nurse's best response?

Depending on the drug, it may be as long as 2 years ."

A patient with TB asks how to protect family members from the disease. Which discharge instruction given by the nurse is most informative?

"You should always cover your mouth and nose if coughing or sneezing."

A nurse is providing education to a patient taking rifampin as a result of an exposure to TB. What side effect of this drug should the nurse include?

Body fluids to become red-orange

A patient with asthma asks the purpose of learning how to use a peak expiratory flow rate (PEFR) device. What is the nurse's best response regarding PEFR?

Measures expired air to evaluate ventilation

A nurse is assigned to care for a patient with the diagnosis of centriacinar (centrilobar) emphysema. What is a characteristic of this type of emphysema?

Enlarged and broken down bronchioles with intact alveoli

Which assessment made by a nurse indicates that respiratory arrest is imminent in a patient with asthma?

Absence of wheezing

A patient with COPD is observed to have extreme shortness of breath when ambulating. Which nursing intervention is most inappropriate?

Bunch all nursing activities and treatments close together.

A nurse recognizes that a patient diagnosed with COPD has a rising level of partial pressure of carbon dioxide (CO2) in arterial blood (PaCO2). How should the nurse interpret this assessment

Respiratory acidosis has begun.

Which early characteristic in a patient with emphysema gives rise to the term pink puffer?

Normal arterial blood gases (ABGs)

A patient with cystic fibrosis (CF) furiously refuses any more manual chest physiotherapeutic treatment. Which alternative is appropriate for the nurse to suggest?

Flutter mucus device

What should a nurse expect when assessing the CBC results of a patient with chronic bronchitis?

Increased red blood cells (RBCs)

A patient with COPD delightedly tells the nurse that he has quit smoking and is using chewing tobacco. What is the most appropriate nursing intervention?

Warn him of the dangers of oral cancer.

A newly diagnosed patient with non-small cell lung carcinoma (NSCLC) is anxious about upcoming surgery. Which intervention by the nurse would be most helpful?

Support the patient in preparation for surgery.

What should a patient who had the BCG (Bacillus Calmette-Guérin) vaccine 2 years ago anticipate?

False-positive result from TB skin tests

A nurse explains to a family how the asthma attack progresses by using a progressive list of pathologic events. (Place the options in the correct sequence. Do not separate answers with a space or punctuation. Example: ABCD.)

Triggering of inflammatory process, bronchoconstriction, production of mucous plugs, ventilation-perfusion mismatch, hypoxemia with compensatory hyperventilation

study

ユーザ名非公開 · 61問 · 1年前

study