Exam 4 Study Guide PDF

The nursing is caring for a 3-year-old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up? a. Reports of a sore throat b. Heat rate of 112 beat/min c. Frequent swallowing d. Hypotonic bowel sounds **Ans: C** 2. Wha...

The nursing is caring for a 3-year-old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up? a. Reports of a sore throat b. Heat rate of 112 beat/min c. Frequent swallowing d. Hypotonic bowel sounds **Ans: C** 2. What information should the nurse teach families about reducing exposure to pollens and dust? (Select all that apply) e. Replace wall-to-wall carpeting with wood and tile floors f. Use an air conditioner g. Keep pet's outside h. Keep humidity in the house above 60% i. Put dust-proof covers on pillows and mattresses **Ans: A, B, E** 3. A 5-year-old is brought to the emergency department with copious drooling and a croaking sound on inspiration. Her mother states that the child is very agitated and only wants to sit upright. What action by the nurse takes priority? j. Prepare intubation equipment and call the provider k. Examine the child's oropharynx and call the provider l. Obtain a throat culture for respiratory syncytial virus (RSV) m. Obtain vital signs and listen to breath sounds **Ans: A** 4. A child has a chronic, nonproductive cough and diffuse wheezing during the expiratory phase of respiration. What action by the nurse is most appropriate? n. Give ordered antibiotics on time o. Assess the airway for a foreign body p. Provide oxygen via face tent q. Prepare to administer a bronchodilator **Ans: D** 5. A nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Choose the interventions that would be included in the plan of care. (Select all that apply) r. Place the infant in a private room s. Ensure that the infant's head is in a flexed position t. Position the infant side-lying, with the head lower than the chest u. Place the infant in a room near the nurses' station v. Place the child in a tent that delivers cool, humidified air **Ans: A, D, E** 6. An infant diagnosed with congenital laryngeal stridor has noisy, crowing inspiratory sounds with retractions. What is the priority therapeutic management of congenital laryngeal stridor (Croup)? w. Assessment of capillary refill x. Keep the client hydrated y. Maintain patent airway z. Treat the infection **Ans: C** 7. A 16-year-old client with cystic fibrosis is admitted with increased shortness of breath and possibly pneumonia. Which nursing activity is most important to include in the client's care? a. Place the patient in a private room to decrease the risk of further infection b. Perform postural drainage and chest physiotherapy every 4 hours c. Allow the patient to decide whether she needs aerosolized medication d. Plan activities to allow at least 8 hours of uninterrupted sleep **Ans: B** 8. Which statement indicates that a parent of a toddler needs more education about preventing foreign body aspiration? e. "I keep objects with small parts out of reach" f. "My toddler loves to play with balloons" g. "I won't permit my child to have peanuts" h. "I never leave coins where my child could get them" **Ans: B** 9. The nurse should implement which interventions for an infant experiencing apnea? (Select all that apply) i. Suctions the infant j. Stimulate the infant by gently tapping the foot k. Have resuscitative equipment available l. Shake the infant vigorously m. Maintain a neutral thermal environment **Ans: B, C, E** 10. A home health care nurse is doing a home assessment for a family whose child is oxygen dependent. What finding by the nurse requires intervention? n. Oxygen tank is placed 3 feet away from the heater o. Fire extinguisher expires at the end of the month p. Smoking is not allowed in the house q. Tanks are stored only in an upright position **Ans: A** 11. Which statement made by a parent about intervention for a child's fever shows the need for further education? r. "I should keep her covered lightly when she has a fever" s. "I'll give her plenty of liquids to keep her hydrated" t. "I'll look for over-the-counter aspirin or ibuprofen" u. "I can give her acetaminophen for a fever" **Ans: C** 12. Which intervention is appropriate for a hospitalized child who has crops of lesions on the trunk that appear as a macular rash and vesicles? v. Place the child in a strict isolation with airborne and contact precautions w. Pregnant women should avoid contact with the child x. Screen visitors for immunity to measles y. Continue to practice Standard Precautions **Ans: A** 13. A parent asks the nurse how she will know whether her child has fifth disease. The nurse should advise the parent to be alert for which manifestations? z. Maculopapular rash on the trunk that lasts for 2 days a. Lesions in various stages of development on the trunk b. Bull's eye rash at the site of a tick bite c. Bright red rash on the cheeks that looks like slapped cheeks **Ans: D** 14. The A nurse is caring for a 15-year-old diagnosed with Epstein-Barr virus. Which tasks are most important for the nurse to delegate to the UAP? (Select all that apply) d. Offer mash potatoes e. Provide an educational pamphlet to the client f. Document any rashes that are present g. Assess the client abdomen h. Offer milkshakes **Ans: A, E** 15. The mother of an infant with multiple anomalies tells the nurse that she had a viral infection in the beginning of her pregnancy. Which viral infection is associated with fetal anomalies? i. Herpes simplex virus j. Measles k. Rubella l. Roseola **Ans: C** 16. What should the nurse expect to observe in the prodromal phase of rubeola? m. Kolpik spots n. Petechiae on the soft palate o. Macular rash on the face p. Crops of vesicles on the trunk **Ans: A** 17. Which treatment would the nurse expect in a client admitted to the hospital with fever, chills, night sweats, fatigue, and weight loss who is found to have a mitral heat murmur on auscultation of the chest 2 weeks after dental surgery? q. Sodium restricted diet r. Cardiac transplantation s. Intravenous antibiotics t. Pericardiocentesis **Ans: C** 18. A child's ear is examined by the healthcare provider who noted bulging opaque tympanic membrane, yellowish drainage, of the right tympanic membrane. What additional findings would the nurse ask the mother to report? (Select all that apply) u. Positive pressure on the tympanogram v. Irritability w. Movement of the tympanic membrane x. Elevated temperature of 101 degrees y. Otalgia **Ans: B, D, E** 19. Which treatment would the nurse anticipate when caring for a preschooler with Kawasaki disease? z. Administering intravenous immune globin (IVIG) as prescribed a. Ensuring bright lighting in the room during assessments b. Administering penicillin G benzathine (Bicillin) as prescribed c. Restricting fluids, especially fruit juices **Ans: A** 20. Penicillin G procaine, 1,000,000 units IM, is prescribed for an adolescent with an infection. The medication label reads "1,200,000 units per 2mL". The nurse has determined that the dose prescribed is safe. The nurse administers how many milliliters per dose to the adolescent? ***Round answer to the nearest tenth position.*** d. 0.8 mL e. 1.7 mL f. 1.4 mL g. 1.2 mL **Ans: B** 21. The nurse is caring for a client diagnosed with a pneumothorax, the client has an anterior and posterior chest tube. Which areas of assessment are priority in the care of this client? (select all that apply) h. Peripheral edema i. Dressing drainage j. Breath sounds k. Bubbling in water chamber l. Temperature **Ans: B, C, D** 22. A nurse is caring for a client who has had anterior nasal packing for severe epistaxis. Which assessment finding is priority for the nurse to report to the health care provider? m. Nasal discomfort n. Dry mouth o. Excessive saliva p. Frequent swallowing **Ans: D** 23. A nurse has to assist a client with epistaxis. Which action should the nurse implement first? q. Sit the client upright r. Donn disposable gloves s. Apply direct pressure t. Pack the nares with gauze **Ans: B** 24. A nurse assesses a client after a thoracentesis. Which assessment finding is priority for the nurse to notify the health care provider? u. Pulse oximetry 93% v. Absent breath sounds w. Pain 5/10 on pain scale x. Small drainage from the site **Ans: B** 25. A nurse cares for a client who had a laryngoscopy 2 hours ago. The client asks for a drink of water. Which intervention is priority for the nurse to implement? y. Provide ice chips z. Give small sips a. Provide a straw with the water b. Assess gag reflex **Ans: D** 26. The nurse is providing instructions on tracheostomy to a client's daughter. What action by the daughter indicates that more teaching is needed? c. Suctioned for a total of three times when needed d. Preoxygenated the client prior to suctioning e. Applying suction while inserting the catheter f. Suctioned for only 10 to 15 seconds each time **Ans: C** 27. A nurse assesses a client who is prescribed fluticasone (Flovent) and note oral lesions. Which client teaching should the nurse implement? g. Eat before using h. Take with food i. Rinse mouth after use j. Drink plenty of fluids **Ans: C** 28. The healthcare provider prescribes theophylline for a client with asthma. Which is priority for the nurse to monitor when administering this medication? k. Daily weights l. Drug level m. Productive cough n. Edema of the extremity **Ans: B** 29. The nurse is caring for a post-operative tonsillectomy client. Which interventions should the nurse include in the plan of care? (Select all that apply) o. Monitor I & O p. Keep head of bad flat q. Monitor for bleeding r. Assess NG tube patency s. Hyperextend head **Ans: A, C** 30. An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which would be priority for the nurse to teach? t. Use of protective equipment u. Symptoms of lung disease v. Side effects of drugs w. Sodium restricted diet **Ans: A** 31. Which of the following clinical assessment in a client indicates serious complications of COPD? x. PaO2 79 y. Creatinine 1.5gtt/dL z. CO2 65 a. BUN 20 mg/dL **Ans: C** 32. A client diagnosed with allergic rhinitis is prescribed diphenhydramine. When taking this medication, which instruction is priority for the nurse to provide? b. Take with food c. Avoid driving d. Rinse mouth e. Do not crush **Ans: B** 33. A client is receiving oxygen at 6 liters per nasal cannula. Which task should the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply) f. Monitor respiratory rate g. Apply water-soluble ointment to nares h. Encourage use of incentive spirometry i. Monitor oxygen saturation j. Adjust oxygen as needed **Ans: A, B, D** 34. A client presents to the emergency department after sustaining an open chest wound from a penetrating object. What is a priority nursing action for this client? k. Remove the object l. Reposition on unaffected side m. Assess asymmetric chest movement n. Apply dry dressing **Ans: C** 35. A client who had a laryngectomy is being transferred from the surgical unit. Which is the most important equipment to place at the client's bedside? o. Suction catheter p. Paper and pen q. Humidified oxygen r. Incentive spirometry **Ans: A** 36. A nurse is assigned several clients who have a history of asthma. Which client should the nurse assess first? s. The client who is coughing up yellowish sputum t. The client with a heart rate of 120 beats/min u. The client with a barrel chest and clubbed fingernails v. The client with an oxygen saturation level of 92% at rest **Ans: B** 37. A client in a long-term care facility has a tracheostomy. When providing tracheostomy care, which intervention should the nurse implement first? w. Change tracheostomy ties x. Suction tracheostomy y. Remove old dressing z. Open sterile normal saline **Ans: B** 38. A client has a chest tube connected to a water-seal drainage system that is attached to suction. What is the priority intervention for the nurse to implement when excessive bubbling is observed in the water-seal chamber? a. Strip the chest tube catheter b. Milk the drainage tube c. Decrease the amount of suction d. Assess system for air leak **Ans: D** 39. A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this clients teaching? e. "You will have to remove the carpet in your home" f. "It would be best to keep hairy pets outside the house" g. "Be sure to include nutritious diet" h. "Your child should exercise for 30 minutes" **Ans: C** 40. A nurse evaluates the following arterial blood gas results for a client with chronic obstructive pulmonary disease (COPD): pH 7.32 PaCO2 62 mm Hg PaO2 46 mm Hg HCO3 28 mEq/L. Which prescription should the nurse implement first? i. Apply oxygen at 2L/NC j. Perform chest physiotherapy k. Administer albuterol inhaler l. Call for stat chest x-ray **Ans: A** 41. A client has a prescription for 500ml of 0.9% NS IV over 4 hours for oliguria. The drop factor is 10gtt/ml. How many drops per minute should be given? m. 21 gtt/min n. 20 gtt/min o. 13 gtt/min p. 83 gtt/min **Ans: A** 42. Which action would the nurse implement to reduce the risk of aspiration pneumonia in an unconscious client? q. Position on alternating sides with HOB elevated r. Position upright with neck bent slightly forward during meals s. Position on the left side after feedings t. Elevate the HOB during and for 10 minutes after feeding **Ans: A** 43. The nurse reviews newly written prescriptions for a client diagnosed with Influenza B. Which prescription would the nurse question? u. Amantadine 100 mg and rimantadine 100 mg p.o. qhs v. Oseltamivir 75 mg p.o. b.i.d w. Zanamivir inhaler two puffs b.i.d x. Peramivir 600 mg IV times 1 dose **Ans: A** 44. The nurse is assessing a client. Which symptoms is most important to communicate to the primary health care provider (PCHP) when differentiating between the common cold and influenza in the older adult? y. Temperature 102.5 F z. Sneezing a. Earache 7 on a scale 1-10 b. Nasal stuffiness **Ans: A** 45. A client has been taking Isoniazid for six weeks and complains of numbness and tingling in the extremities. The nurse is correct to suspect that the client is experiencing which complication of this medication? c. Small vessel spasms d. Impaired peripheral circulation e. Peripheral neuropathy f. Deep vein thrombosis **Ans: C** 46. A nurse is preparing discharge planning for a female client with very painful urination. Which statement by the client indicates a need for further instructions? g. "I will continue to use vaginal spray" h. "I will drink fluid during the day and night" i. "I will take warm sitz bath" j. "I will wear cotton undergarments" **Ans: A** 47. The nurse is caring for a client with and indwelling catheter. What actions would the nurse implement to decrease the risk of an infection? (Select all that apply) k. Keep the drainage system open l. Flushing the tubing as needed m. Keep the drainage bag below the level of the bladder n. Use standard precaution o. Provide perineal care twice a day **Ans: C, D, E** 48. A client has just been admitted to the hospital with a diagnosis of probable bacterial pneumonia. Which prescription would the nurse implement first? p. Administer acetaminophen suppository q. Obtain blood cultures from 2 sites r. Administer Ciprofloxacin 400 mg IV s. Encourage coughing and dep breathing exercises **Ans: B** 49. A client has been prescribed Isoniazid (INH) for six weeks. Which of the following are foods that should be avoided during therapy? t. Organ meats and beef u. Aged cheese and smoked fish v. Oranges and all forms of citrus w. Red wires and beer **Ans: B** 50. A nurse is caring for a client diagnosed with Mycobacterium Tuberculosis. What are the most suitable safety precautions that should be implemented? (Select all that apply) x. Airborne isolation y. N-95 mask z. Industrial mask a. Droplet isolation b. Goggles and surgical mask **Ans: A, B** 51. The nurse is preparing discharge teaching for a client with active tuberculosis. Which statement by the client indicate the additional instructions are needed? c. "I will spend a lot of time outdoors" d. "I will take all my medication as prescribed" e. "I will open the windows in my room" f. "I will now be able to sleep with my spouse" **Ans: D** 52. A nurse is caring for a client diagnoses with viral conjunctivitis. Which PHCP prescription would the nurse question? g. Idoxuridine ointment h. Topical antibiotic i. HerpEX ointment j. Corticosteroids **Ans: D** 53. A malnourished client is admitted to the hospital with bacteria pneumonia, temp 103.5 F, respirations 28, complaints of chills, and shortness of breath. Which problem should the nurse plan to address first? k. Inadequate nutrition l. Inadequate oxygenation m. Elevated temperature n. Fluid volume deficit **Ans: B** 54. The nurse is admitting a client to the unit with pneumonia and fluid volume deficit. Which assessment findings should the nurse anticipate? (Select all that apply) o. Decreased skin turgor p. Elevated hematocrit q. Moist mucous membranes r. Thick secretions s. Diluted urine **Ans: A, B, D** 55. The nurse is preparing a discharge teach plan for a client with pneumonia. Which instructions should be included in the discharge plan? (select all that apply) t. Avoid others who have colds or infections u. Ensure you are getting plenty of fluids v. Use a soft toothbrush and electronic razor w. Take all medicines as prescribed x. Avoid aspirin **Ans: A, B, D** 56. A client with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? y. Encourage the client to wear the nasal O2 cannula z. Help the client to splint the chest when coughing a. Restrict oral fluids during the day b. Encourage pursed lip breathing **Ans: B** 57. A client who is taking rifampin calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication? c. Ask the client about any visual changes in red-green color discrimination d. Question the client about experiencing shortness of breath and hives e. Explain that orange discolored urine and tears are normal with this medicine f. Advise the patient to stop the drug and report symptoms to PHCP **Ans: C** 58. A client diagnosed with active tuberculosis is homeless. Which interventions by the nurse would be most effective in ensuring adherence with the treatment regimen? g. Arrange for the patient's friend to administer the medicine h. Repeat warning about the high risk for infecting others i. Arrange for a daily meal and drug administration at the clinic j. Give the patient written instructions about how to take the medicine **Ans: C** 59. A nurse working on the pulmonary unit has a tuberculosis skin test of 16-mm induration, a negative chest x-ray, and no symptoms of TB. Which information should be included in the teaching plan? k. Need for annual repeat TB skin testing l. Standard four-drug therapy for TB m. Use and side effects of isoniazid n. Bacilli Calmette-Guerin vaccine **Ans: C** 60. A client with cystitis who weighs 132 lbs. is instructed to drink 30 mL/Kg of fluid each day. How much fluid will the client consume each day? o. 2000 ml p. 2727 ml q. 3960 ml r. 1800 ml **Ans: D**