-cocci Berry shaped bacteria.

-graph Instrument to record.

-oid Resembling

-ptosis Prolapse

-scope Instrument to visually examine.

-stomy Surgical creation of a permanentopening to the outside of the body.

-therapy Treatment.

A 25-year-old client was admitted yesterday after a motor vehiclecollision. Neurodiagnostic studies showed a basal skull fracture inthe middle fossa. Assessment on admission revealed both halo andBattle signs. Which new symptom indicates that the client is likelyto be experiencing a common life-threatening complicationassociated with basal skull fracture?

A. Bilateral jugular vein distention.B. Oral temperature of 102 degrees F.C. Intermittent focal motor seizures.D. Intractable pain in the cervical region.

B. Increased temp indicatesmeningitis. (C & D) these symptomsmay be exhibited but are not lifethreatening. (A) JVD is not a typicalcomplication of basal skull fractures.

39. Select all that apply. Which of the following areclinical manifestations of tension pneumothorax? A. Midline trachea B. Severe hypertension C. Progressive cyanosis D. A loud bruit on affected side E. Asymmetrical chest wall movement F. Subcutaneous emphysema in the neck

C,E, F The indicators of tensionpneumothorax are asymmetricalchest wall movement, severehypotension, subcutaneousemphysema in the neck and upperchest, and progressive cyanosis.

41. Select all that apply. During initial assessment, anurse should record which of the followingmanifestations of respiratory distress? A. Tachypnea B. Nasal flaring C. Thready pulse D. Panting or grunting E. Use of intercostal muscles F. An inspiratory-to-expiratory ratio of 1:2

AD Manifestations of respiratorydistress include tachypnea, gruntingand panting on respiration, centralcyanosis, use of accessory muscles,and flaring nares.

42. Select all that apply. Which of the followingnursing actions can help clear tracheobronchialsecretions in a patient with cystic fibrosis? A. Postural drainage B. Suppressing the cough C. Ensuring adequate hydration D. Administering mucolytic aerosols E. Encouraging the patient to lie flat F. Administering water-soluble vitamins

ACD Postural drainage, adequatehydration, and administration ofmucolytic aerosols all encouragecoughing and the clearing of secretions.A patient with cystic fibrosis will be morecomfortable sitting upright.

A 43-year-old homeless, malnourished female client with a historyof alcoholism is transferred to the ICU. She is placed on telemetry,and the rhythm strip shown is obtained. The nurse palpates a heartrate of 160 beats/min, and the client's blood pressure is 90/54.Based on these finding, which IV medication should the nurseadminister?

A. Amiodarone (Cordarone)B. Magnesium sulfateC. Lidocaine (Xylocaine)D. Procainamide (Pronestyl)

B. Because the client has chronic alcoholism, she is likelyto have hypomagnesium. (B) is the recommended drugfor torsades de pointes (AHA, 2005), which is a form ofpolymorphic ventricular tachycardia (VT), usuallyassociated with a prolonged QT interval that occurs withhypomagnesemia. (A and D) increase the QT interval,which can cause the torsades to worsen. (C) is theantiarrhythmic of choice in most cases of drug-inducedmonomorphic VT, not torsades.

43. Select all that apply. Which of the following isincluded in a comprehensive respiratory assessment?A. Pulse oximetry B. Chest auscultation C. Apical radial pulse D. Nail-bed assessment E. Evaluation of respiratory effort F. Rate and character of respirations

ABDEF The total assessment of therespiratory system includes pulseoximetry; auscultation; skin and nail-bedassessment for the detection of cyanosis;and rate, character, and degree of effortof respirations. The apical radial pulse isa cardiac assessment.

A 45-year-old man with asthma is brought to theemergency department by automobile. He is short ofbreath and appears frightened. During the initial nursingassessment, which of the following clinical manifestationsmight be present as an early symptom during anexacerbation of asthma? A. Anxiety B. Cyanosis C. Hypercapnia D. Bradycardia

A. Anxiety An early symptom during anasthma attack is anxiety because he isacutely aware of the inability to getsufficient air to breathe. He will behypoxic early on with decreased PaCO2and increased pH as he ishyperventilating.

A 55-year-old male client is admitted to the coronarycare unit having suffered an acute myocardialinfarction (MI). Within 24 hours of the occurrence,the nurse can expect to find which systemic sign?

A. Elevated serum amylase levelB. Elevated CM-MB levelC. Prolonged prothrombin time (PT)D. Elevated serum BUN and creatinine

B. Tissue damage in the myocardium causes the release ofcardiac enzymes into the blood system. An elevated CM-MB is a recognized indicator of an MI. It peaks 12 - 24hours 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 acuteMI it is usually associated with dehydration, high proteinintake or gastrointestinal bleeding and creatine levelsindicate renal damage. (C) Indicates effectiveanticoagulation therapy.

A 58-year-old client, who has no health problems, asks the nurse about takingthe pneumococcal vaccine (Pneumovax). Which statement give by the nursewould offer the client accurate information about this vaccine?

A. "The vaccine is given annually before the flue season to those over 50 yearsof age."B. "The immunization is administered once to older adults or persons with ahistory of chronic illness."C. "The vaccine is for all ages and is given primarily to those person travelingoverseas to infected areas."D. "The vaccine will prevent the occurrence of pneumococcal pneumonia for upto 5 years."

B. It is usually recommended that personsover 65 years of age and those with a historyof chronic illness should receive the vaccineonce in a lifetime. (A) the influenza vaccine isgiven annually. (C) travel is not the mainrationale for the vaccine. (D) The vaccine isusually given once in a lifetime.

A 71-year-old patient is admitted with acute respiratory distressrelated to cor pulmonale. Which of the following nursinginterventions is most appropriate during admission of this patient?A. Delay any physical assessment of the patient and review withthe family the patient's history of respiratory problems. B. Performa comprehensive health history with the patient to review priorrespiratory problems. C. Perform a physical assessment of the respiratory system and askspecific questions related to this episode of respiratory distress. D. Complete a full physical examination to determine the effect ofthe respiratory distress on other body functions.

C. Perform a physical assessment of the respiratorysystem and ask specific questions related to thisepisode of respiratory distress.Because the patient ishaving respiratory difficulty, the nurse should askspecific questions about this episode and perform aphysical assessment of this system. Further historytaking and physical examination of other bodysystems can proceed once the patient's acuterespiratory distress is being managed.

A 75-year-old obese patient who is snoringloudly and having periods of apnea severaltimes each night is most likely experiencing A. narcolepsy. B. sleep apnea. C. sleep deprivation. D. paroxysmal nocturnal dyspnea.

B. sleep apnea. Sleep apnea is most common in obesepatients. Typical symptoms include snoring andperiods of apnea. Narcolepsy is when a patient fallsasleep unexpectedly. Sleep deprivation could resultfrom sleep apnea. Paroxysmal nocturnal dyspneaoccurs when a patient has shortness of breath duringthe night.

absorption atelectasisalveolar collapse that occurs when highconcentrations of oxygen are given andoxygen replaces nitrogen in the alveoli; ifairway obstruction occurs, the oxygen isabsorbed into the bloodstream and thealveoli collapse.

Absorption of vitamin B12 may be decreased in olderadults because of decreased A. intestinal motility. B. production of bile by the liver. C. production of intrinsic factor by the stomach. D. synthesis of cobalamin (vitamin B12) by intestinalbacteria.

C. production of intrinsic factor by the stomach. Older persons are at risk fordeficiency of cobalamin (pernicious anemia) because of a naturally occurringreduction of the intrinsic factor by the stomach mucosa. Absorption ofcobalamin relies on intrinsic factor. Both must be present for absorption.Megaloblastic anemia is related to folate dysfunction. Intestinal motility(peristalsis) is the motion that moves food down the GI tract. The rhythmiccontractions of muscles cause wave-like motions. Lack of peristalsis is called"paralytic ileus." Bile is produced in the liver, is stored and concentrated in thegallbladder, and is released into the duodenum when fat is eaten. Bileemulsifies fats and prepares them for enzyme digestion in order for thenutrient to be absorbed into lymph and eventually into blood vessels to theliver. Vitamin K (the blood-clotting vitamin) is synthesized by intestinalbacteria.

ACE inhibitorcough os a common side effect

hypertensiondo not stop abruptly (rebound

hypertension may occur)

Acromegaly Enlargement of extremities afterpuberty due to pituitary glandproblem.

acute bronchitis an inflammation of the lowerrespiratory tract that is usually due toinfection.

Adipose Pertaining to fat.

adventitious soundsextra breath sounds that are notnormally heard, such as crackles,

rhonchi, wheezes, and pleural frictionrubs.

After a posterior nasal pack is inserted by a physician, thepatient is very anxious and states, "I don't feel like I'mbreathing right." The immediate intervention the nurseshould initiate is to A. monitor ABGs. B. reassure the patient that this is normal discomfort. C. cut the pack strings and pull the packing out with ahemostat. D. direct a flashlight into the patient's mouth and inspectthe oral cavity.

D. direct a flashlight into the patient's mouth andinspect the oral cavity. The nurse should inspect theoral cavity for the presence of blood, soft palatenecrosis, and proper placement of the posterior plug.If the posterior plug is visible, the physician shouldbe notified for readjustment of the packing.Reassurance, cutting the strings, and ABGs are nottop priority interventions. The nurse needs furtherdata before intervening.

After admitting a patient to the medical unit with adiagnosis of pneumonia, the nurse will verify thatwhich of the following physician orders have beencompleted 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 thesputum for culture and sensitivity was sent to the laboratory beforeadministering the cefotetan. It is important that the organisms arecorrectly identified (by the culture) before their numbers are affectedby the antibiotic; the test will also determine whether the properantibiotic has been ordered (sensitivity testing). Althoughantibiotic administration should not be unduly delayed whilewaiting for the patient to expectorate sputum, all of the otheroptions will not be affected by the administration of antibiotics.

Aldosteronismlab =decreased serum level of

potassiumhypokalemiahypertension

allergic rhinitis the reaction of the nasal mucosa to aspecific allergen.

alpha 1-antitrypsina serum protein produced by the livernormally found in the lungs thatinhibits proteolytic enzymes of whitecells from lysing lung tissue; geneticdeficiency of this protein can causeemphysema.

Amniocentesis Surgical puncture to remove fluidfrom the sac around the embryo.

angina pectoris when walking=1.assist to seatedposition; 2. sublingual nitroglycerin;3.oxygen 4. wheelchair to room

Angioplasty Surgical repair of blood vessel.

Anticoagulant therapy is used in thetreatment of thromboembolic diseasebecause anticoagulants can A. dissolve the thrombi. B. decrease blood viscosity. C. prevent absorption of vitamin K. D. inhibit the synthesis of clotting factors.

D. inhibit the synthesis of clotting factors.Anticoagulant therapy is based on the premise thatthe initiation or extension of thrombi can beprevented by inhibiting the synthesis of clottingfactors or by accelerating their inactivation. Theanticoagulants heparin and warfarin do not inducethrombolysis but effectively prevent clot extension.

apnea an absence of spontaneousrespirations.

The arterial blood gas (ABG) readings that indicatecompensated respiratory acidosis are a PaCO2 of A. 30 mm Hg and bicarbonate level of 24 mEq/L. B. 30 mm Hg and bicarbonate level of 30 mEq/L. C. 50 mm Hg and bicarbonate level of 20 mEq/L.D. 50 mm Hg and bicarbonate level of 30 mEq/L.

D. 50 mm Hg and bicarbonate levelof 30 mEq/L. If compensation ispresent, carbon dioxide andbicarbonate are abnormal (or nearlyso) in opposite directions (e.g., one isacidotic and the other alkalotic).

Arteriole Small artery.

asthma

a chronic inflammatory lung disease thatresults in airflow obstruction;characterized by recurring episodes ofparoxysmal dyspnea, wheezing onexpiration and/or inspiration caused byconstriction of the bronchi, coughing,and viscous mucoid bronchial secretions.

Before beginning a transfusion of RBCs, which of the following actions by the nurse would be ofhighest priority to avoid an error during this procedure? A. Check the identifying information on the unit of blood against the patient's ID bracelet. B. Select new primary IV tubing primed with lactated Ringer's solution to use for thetransfusion. C. Add the blood transfusion as a secondary line to the existing IV and used the IV controller tomaintain correct flow. D. Remain with the patient for 60 minutes after beginning the transfusionto watch for signs of a transfusion reaction. The patient's identifying information (name, date ofbirth, medical record number) on the identification bracelet should exactly match theinformation on the blood bank tag that has been placed on the unit of blood. If any informationdoes not match, the transfusions should not be hung because of possible error and risk to thepatient.

A. The patient's identifying information (name,date of birth, medical record number) on theidentification bracelet should exactly match theinformation on the blood bank tag that has beenplaced on the unit of blood. If any informationdoes not match, the transfusions should not behung because of possible error and risk to thepatient.

Before discharge, the nurse discusses activity levels with a61-year-old patient with COPD and pneumonia. Which ofthe following exercise goals is most appropriate once thepatient is fully recovered from this episode of illness? A. Slightly increase activity over the current level. B. Walk for 20 minutes a day, keeping the pulse rate lessthan 130 beats per minute. C. Limit exercise to activitiesof daily living to conserve energy. D. Swim for 10 min/day, gradually increasing to 30min/day.

B. Walk for 20 minutes a day, keeping the pulse rateless than 130 beats per minute. The patient willbenefit from mild aerobic exercise that does notstress the cardiorespiratory system. The patientshould be encouraged to walk for 20 min/day,keeping the pulse rate less than 75% to 80% ofmaximum heart rate (220 minus patient's age).

Before starting a transfusion of packed red bloodcells for an anemic patient, the nurse would arrangefor a peer to monitor his or her other assignedpatients for how many minutes when the nursebegins the transfusion? A. 60 B. 5 C. 30 D. 15

D. 15 As part of standard procedure, thenurse remains with the patient for thefirst 15 minutes after hanging a bloodtransfusion. Patients who are likely tohave a transfusion reaction will moreoften exhibit signs within the first 15minutes that the blood is infusing.

Bell palsy (7th crainal nerve) unilateral facial weakness andparalysis

The blood bank notifies the nurse that the two units of bloodordered for an anemic patient are ready for pick up. The nurseshould take which of the following actions to prevent an adverseeffect during this procedure? A. Immediately pick up both units of blood from the blood bank. B. Regulate the flow rate so that each unit takes at least 4 hours totransfuse. C. Set up the Y-tubing of the blood set with dextrose in water as theflush solution. D. Infuse the blood slowly for the first 15 minutes of thetransfusion.

D. Infuse the blood slowly for the first 15 minutes ofthe transfusion. Because a transfusion reaction ismore likely to occur at the beginning of a transfusion,the nurse should initially infuse the blood at a rate nofaster than 2 ml/min and remain with the patient forthe first 15 minutes after hanging a unit of blood.

blunt trama to back of head LOC assessment most important

cancerreduce fats

increase fruits, vegetables and fiberie bran flakes, skim milk, orange

slices

Catabolism The process by which food is burnedto realease energy.

Cell Membrane Allows materials to pass into and outof the cell.

A central venous catheter has been inserted via a jugular vein and aradiography has confirmed placement of the catheter. Aprescription has been received for stat medication but IV fluidshave not yet been started. What action should the nurse take priorto administering the prescribed medication?

A. Assess for signs of jugular vein distention.B. Obtain the needed intravenous solution.C. Administer a bolus of normal saline solution.D. Flush the line with heparinized saline.

C. A medication can be administered central linewithout IV fluids, flush with normal saline to removeheparin that may counteract with the medication. (B)is used following the medication and a second salinebolus. (A) will not impact the the med administrationand is not a priority. (B) Administration of the statmedication is more of a priority than (B).

centrilobular emphysematype of emphysema often associated withchronic bronchitis in which respiratorybronchioles enlarge, the walls are destroyed,and the bronchioles become confluent;characterized by enlargement of air spaces inthe proximal part of the acinus, primarily atthe level of the respiratory bronchioles.

chemoreceptora sensory nerve cell that responds to

a change in the chemical composition(PaCO2 and pH) of the fluid around

it.

chest percussion rhythmic percussion of a patient'schest with cupped hands to loosenretained respiratory secretions.

chest physiotherapya series of maneuvers includingpercussion, vibration, and posturaldrainage designed to promoteclearance of excessive respiratorysecretions.

chest tube decreased drainage =assess for kinksor dependant loops -do not clamp off

Chronic Continuing over a long period oftime.

chronic bronchitis

obstructive pulmonary diseasecharacterized by excessive production ofmucus and chronic inflammatorychanges in the bronchi, resulting in acough with expectoration for at least 3months of the year for more than 2consecutive years.

The chronic inflammation of the bronchicharacteristic of chronic obstructive pulmonarydisease (COPD) results in A. collapse of small bronchioles on expiration. B. permanent, abnormal dilation of the bronchi. C. hyperplasia of mucus-secreting cells and bronchialedema. D. destruction of the elastic and muscular structuresof the bronchial wall.

C. hyperplasia of mucus-secreting cells and bronchialedema. Chronic bronchitis is characterized by chronicinflammation of the bronchial lining, with edema andincreased mucus production. Collapse of smallbronchioles on expiration is common in emphysema,and abnormal dilation of the bronchi because ofdestruction of the elastic and muscular structures ischaracteristic of bronchiectasis.

chronic pancreatitispulmonary disease state characterized by thepresence of airflow obstruction caused bychronic bronchitis or emphysema; clinicaluse of the term indicates the presence ofchronic bronchitis and/or emphysema;includes asthma, chronic bronchiectasis,chronic bronchitis, and emphysema.

chylothorax a condition marked by lymphaticfluid in the pleural space caused by aleak in the thoracic duct.

cirrhosisVitamin K1 (AquaMephyton)high calorie, low sodium dietsodium restriction w/ edemafluids restricted to decrease asciteslate stage = ascites

CKD chronic kidney diseaseprior to hemodialysis lab=

hypocalcemia due tohyperphosphatemia, hyperkalemic &

hypernatremic

A client diagnosed with angina pectoris complains ofchest pain while ambulating in the hallway. Whichaction 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 andthen administer (C & D). Then theclient can be escorted back to theroom via wheelchair or stretcher (B).

A client diagnosed with chronic kidney disease (CDK) 2years ago is regularly treated at a communityhemodialysis facility. In assessing the client before hisscheduled dialysis treatment, which electrolyte imbalanceshould the nurse anticipate?

A. HypophosphatemiaB. HypocalcemiaC. HyponatremiaD. Hypokalemia

B. Hypocalcemia develops in CKDdue to chronic hyperphosphatemianot (A). (C & D) incorrect you wouldfind hypernatremia andhyperkalemia

A client is placed on a mechanical ventilator following a cerebralhemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kgevery 12 hours IV is prescribed. What is the priority nursingdiagnosis for this client?

A. Impaired communication related to paralysis of skeletalmuscles.B. Hight risk or infection 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 theendotracheal intubation and/or mechanicalventilation, a skeletal-muscle relaxant such asvecuronium is usually prescribed. (A) is a seriousoutcome because the client cannot communicatehis/her needs. (D) is not as much of a priority. (B)infection is not related to ICP. (C) is incorrectbecause the ventilator will ensure that the lungs areexpanded.

A client who is receiving an ACE inhibitor for hypertension calls theclinic and reports the recent onset of a cough to the nurse. What actionshould the nurse implement?

A. Advise the client to come to the clinic immediately for furtherassessment.B. Instruct the client to discontinue use of the drug, and make anappointment at the clinic.C. Suggest that the client lear to accept the cough as a side effect to anecessary prescription.D. Encourage the client to keep taking the drug until seen by the HCP.

D. Cough is a common s/e of ACE inhibitors and isnot an indication to discontinue the medication. (A)immediate evaluation is not needed. (B) anantihypertensive should not be stopped abruptly. (C)is demeaning since the cough may be disruptive tothe client and other medications may produce resultswithout the s/e.

A client with alcohol-related liver disease is admittedto the unit. Which prescription should the nursequestion as possibly inappropriate for the client?

A. Vitamin K1 (AquaMEPHYTON) 5 mg IM dailyB. High-calorie, low-sodium dietC. Fluid restriction to 1500 ml/dayD. Pentobarbital (Nembutal sodium) 50 mg atbedtime for rest

D. Sedatives such as Nembutal are contraindicatedfor clients with liver damage and can have dangerousconsequences. (A) is often prescribed since normalclotting mechanism is damaged. (B) is needed torestore energy. (C) Fluids are restricted to decreaseascites which often accompanies cirrhosis,particularly in later stages of the disease.

A client with chronic asthma is admitted to postanesthesia complainingof pain at level 8 of 10, with a BP of 124/78, pulse of 88 beats/min, andrespirations of 20 breaths/min. The postanesthesia recoveryprescription is, "Morphine 2 to 4 mg IV push while in recovery for painlevel 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 remainselevated.

B. Call for a different medication becausemorphine and meperidine (Demerol)have histamine-releasing narcotics andshould be avoided when a client hasasthma. (A) puts the client at risk forasthma attack. (C & D) disregard theclients prescription and pain relief.

A client with cirrhosis states that his disease wascause by a blood transfusion. What informationshould the nurse obtain first to provide effectiveclient teaching?

A. The year the blood transfusion was receivedB. The amount of alcohol the client drinksC. How long the client has had cirrhosisD. The client's normal coping mechanisms

A. The nurse should first verify the clientsexplanation (A) since it may be accuratedue to prior to 1990 blood was notscreened for Hep C and hep C can causecirrhosis. Not all cirrhosis is caused iscaused by alcoholism (B) (C & D) provideuseful but less relevant information.

A client with hypertension has been receiving ramipril (Altace) 5mg 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 shouldthe 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 thatthe medication is working. (B & C)would be indicated if the BP was low(systole below 100). (D) is notrequired because the dose is withinmanufacture's recommendations.

Coccyx Tailbone.

community-acquired pneumoniaa lower respiratory tract infection ofthe lung parenchyma with onset inthe community or during the first 2days of hospitalization.

compliance a measure of the ease of expansion ofthe lungs and thorax.

COPD contributing factor=smoking

cor pulmonalehypertrophy of the right side of theheart, with or without heart failure,

resulting from pulmonaryhypertension.

CPR just above the xiphoid process on thelower third of the sternum

crackleshort, low-pitched sounds consisting ofdiscontinuous bubbling caused by airpassing through airway intermittentlyoccluded by mucus, unstable bronchial wall,or fold of mucosa; evident on inspirationand, at times, expiration; similar sound toblowing through a straw under water.

Craniotomy Incision of the skull.

Cushing Syndrome

results from hypersecreationglucocorticoids in the adrenal cortexoften develope diabetes mellitus -monitor serum glucose levelsgenerialized edemalow calorie, low carbohydrate, lowsodium diet

cystic fibrosisan autosomal recessive, multisystemdisease characterized by alteredfunction of the exocrine glandsinvolving primarily the lungs,pancreas, and sweat glands.

Cystocele Hernia of the urinary bladder.

Debilitating anginal pain can be decreased in some clients by theadministration of beta-blocking agents such as nadolol (Corgard). Whichclient requires the nurse to use extreme caution when administeringCorgard?A. A 56-year-old air traffic controller who had bypass surgery 2 yearsago.B. A 47-year-old kindergarten teacher diagnosed with asthma 40 yearsagoC. A 52-year-old unemployed stock broker who refuses treatment foralcoholismD. A 60-year-old retired librarian who takes a diuretic daily forhypertension.

B. asthma must be carefully monitoredbecause beta blockers because it caninduce cardiogenic shock and reducebronchodilation efforts. (A & D) thismedication is indicated and (C) it is notcontraindicated.

deviated septum a deflection of the normally straightnasal septum.

Diaphragm Muscular wall separating theabdominal and thoracic cavities.

diaphragmatic breathing breathing with the use of thediaphragm to achieve maximuminhalation and slow respiratory rate.

digitalis (Lanoxin)digoxin

cardiac glycosidecan build up toxic levels s/s anexoria,

nausea, vomiting, diarrhea,headache, fatigue

Disc A piece of cartilage betweenbackbones.

diverticulititshard ridgid abdomen & elevated WBC =peritonitis = medical emergency shouldbe reported to PCP immediately

s/s left lower quadrant pain; elevatedtemperature; refusing to eat; nausea

DNA Genes are composed of?

dry powder inhaler dry powdered drug delivered byinhalation.

During admission of a patient diagnosed with non-small cell carcinoma of the lung, the nurse questionsthe patient related to a history of which of thefollowing risk factors for this type of cancer? (Selectall that apply.) A. Asbestos exposure B. Cigarette smoking C. Exposure to uranium D. Chronic interstitial fibrosis

A,B,C Non-small carcinoma is associatedwith cigarette smoking and exposure toenvironmental carcinogens, includingasbestos and uranium. Chronicinterstitial fibrosis is associated with thedevelopment of adenocarcinoma of thelung.

During assessment of a 45-year-old patient withasthma, the nurse notes wheezing and dyspnea. Thenurse interprets that these symptoms are related towhich of the following pathophysiologic changes? A.Laryngospasm B. Overdistention of the alveoli C.Narrowing of the airway D. Pulmonary edema

C. Narrowing of the airwayNarrowingof the airway leads to reducedairflow, making it difficult for thepatient to breathe and producing thecharacteristic wheezing.

During assessment of a client in the intensive care unit,the nurse notes that the client's breath sounds are clearupon auscultation, but jugular vein distention andmuffled heart sounds are present. Which interventionshould the nurse implement?

A. Prepare the client for a pericardial tap.B. Administer intravenous furosemide (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 ofcardiac tamponade that results inreduced cardiac output. Treatment ispericardial tap. (B) is not a treatment.(C) is not priority. (D) Fluids arefrequently increased but this is not aspriority as (A).

During care of a patient with multiple myeloma, animportant nursing intervention is A. limiting activity to prevent pathologic fractures. B. assessing for changes in size and characteristics oflymph nodes. C. maintaining a fluid intake of 3 to 4 L/day to dilutecalcium load. D. administering narcotic analgesics continuously tocontrol bone pain.

C. maintaining a fluid intake of 3 to 4L/day to dilute calcium load. Adequatehydration must be maintained tominimize problems from hypercalcemia.The goal of a urinary output of 1.5 to 2L/day requires an intake of 3 to 4 L/day.

During discharge teaching for a 65-year-old patientwith emphysema and pneumonia, which of thefollowing vaccines should the nurse recommend thepatient receive? A. S. aureus B. H. influenzae C. Pneumococcal D. Bacille Calmette-Gurin (BCG)

C. Pneumococcal The pneumococcalvaccine is important for patients witha history of heart or lung disease,recovering from a severe illness, age65 or over, or living in a long-termcare facility.

During report, the nurse learns that a client with tumor lysissyndrome is receiving an IV infusion containing insulin. Whichassessment 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 lysissyndrome may experiencehyperkalemia, therefor it is importantto monitor serum potassium andblood glucose levels. (A, B, D) are notas priority.

During the change of shift report, thecharge nurse reviews the infusionsbeing received by the clients on theoncology unit. The client receivingwhich infusion should be seen first?

C. Has the highest risk for respiratorydepression and therefor should beseen first. (A) Risk of hypotension.(B) Lowest risk. (D) Risk ofnephrotoxicity and phlebitis.

dyspneashortness of breath; difficultybreathing that may be caused bycertain heart conditions, strenuousexercise, or anxiety.

ECGU wave is positive deflectionfollowing theT wave often present in hypokalemia

tall spiked T wave, prolonged QTintervial, widening QRS complex are allsigns of hyperkalemia

elastic recoil the tendency for the lungs to recoil orreduce in volume after beingstretched or expanded.

emphysemaan abnormal condition of the

pulmonary system, characterized byoverinflation and destructive changes

in alveolar walls.

empyemaan accumulation of purulentexudates in a body cavity, especiallythe pleural space, as a result ofbacterial infection, such as pleurisyor tuberculosis.

Endoplasmic Reticulum Part of the cell where formation ofproteins occurs.

epistaxis nosebleed

esophageal speech a method of swallowing air, trappingit in the esophagus, and releasing itto create sound.

esophagogastromyesophageal cancer

risk for infection = meticulious oralcare should be provided several times

a day prior to surgery

An excess of carbon dioxide in the blood causes anincreased respiratory rate and volume because CO2 A. displaces oxygen on hemoglobin, leading to adecreased PaO2. B. causes an increase in the amount of hydrogen ionsavailable in the body. C. combines with water to form carbonic acid, loweringthe pH of cerebrospinal fluid. D. directly stimulates chemoreceptors in the medulla toincrease respiratory rate and volume.

C. combines with water to form carbonic acid, loweringthe pH of cerebrospinal fluid. A combination of excessCO2 and H2O results in carbonic acid, which lowers thepH of the cerebrospinal fluid and stimulates an increasein the respiratory rate. Peripheral chemoreceptors in thecarotid and aortic bodies also respond to increases inPaCO2 to stimulate the respiratory center. Excess CO2does not increase the amount of hydrogen ions availablein the body but does combine with the hydrogen of waterto form an acid.

A family member was taught to suction a client'stracheostomy prior to the client's discharge from thehospital. Which observation by the nurse indicates thatthe family member is capable of correctly performing thesuctioning technique?

A. Turns on the continuous wall suction to -190 mm HgB. Inserts the catheter until resistance or coughing occursC. Withdraws the catheter while maintaining suctioningD. Re-clears the tracheostomy after suctioning the mouth

B. indicates correct technique forperforming suctioning. Suction pressureshould be between -80 and -120 (A). Thecatheter should be withdrawn 1-2 cm at atime with intermittent suction (C). (D)introduces pathogens.

A female client with a nasogastric tube attached to lowsuction states that she is nauseated. The nurse assessesthat there has been no drainage through the nasogastrictube in the last 2 hours. Which action should the nursetake first?

A. Irrigate the nasogastric tube with sterile normal saline.B. Reposition the client on her side.C. Advance the nasogastric tube 5 cm.D. Administer an intravenous antiemetic as prescribed.

B. The priority is to determined if thetube is functioning correctly, whichwould relieve the client's nausea. Theleast invasive intervention is to repositionthe client (B), should be attempted first,followed by (A & C) if these areunsuccessful then (D).

flail chest instability of the chest wall resultingfrom multiple rib fractures.

Following a patient's bone marrow aspiration, whichof the following nursing interventions should a nurseanticipate? A. Application of firm pressure to the site B.Positioning the patient in a prone position C. Positioning the patient in a supine position D. Application of a warm, moist compress to the site

A. Application of firm pressure to the site After abone marrow aspiration procedure, a nurse shouldapply pressure to the aspiration site until bleedingstops. Application of a warm, moist compress will notalter the potential for bleeding. Positioning thepatient to assume a supine or prone position also willnot address the need to control bleeding from theaspiration site.

Following a supraglottic laryngectomy, the patient is taught how touse the supraglottic swallow to minimize the risk of aspiration. Inteaching the patient about this technique, the nurse instructs thepatient to A. perform Valsalva maneuver immediately after swallowing. B. breathe between each Valsalva maneuver and cough sequence. C. cough after swallowing to remove food from the top of the vocalcords. D. practice swallowing thin, watery fluids before attempting toswallow solid foods.

C. cough after swallowing to remove food from the top ofthe vocal cords. A supraglottic laryngectomy involvesremoval of the epiglottis and false vocal cords, and theremoval of the epiglottis allows food to enter the trachea.Supraglottic swallowing requires performance of theValsalva maneuver before placing food in the mouth andswallowing. The patient then coughs to remove food fromthe top of the vocal cords, swallows again, and thenbreathes after the food has been removed from the vocalcords.

fremitus vibration of the chest wall producedby vocalization.

gangrene necrosis/tissue deathpriority prevent infection

hemothorax accumulation of blood in the pleuralspace.

Hepatitis Bhealth care providers should have

Hep B vaccine;transmitted by fecal/oral

contamination

Histologist Person who studies tissues.

The home health nurse is assessing a male client being treated forParkinson disease with levodopa-carbidopa (Sinemet). The nurseobserves that he does not demonstrate any apparent emotionswhen speaking and rarely blinks. Which intervention should thenurse implement?

A. Perform a complete cranial nerve assessment.B. Instruct the client that he may be experiencing medicationtoxicity.C. Document the presence of these assessment findings.D. Advise the client to seek immediate medical evaluation.

C. A mask-like expression and infrequentblinking are common clinical features ofParkinsonism. The nurse shoulddocument the findings. (A & D) are notnecessary. Signs of toxicity (B) aredyskinesia, hallucinations, and psychosis.

hospital-acquired pneumoniapneumonia occurring 48 hours or

longer after hospital admission andnot incubating at the time of

hospitalization.

hypercalcemia positive trousseau sign = carpalspasm

hypercapniagreater than normal amounts of

carbon dioxide in the blood (PaCO2> 45 mm Hg); also called

hypercarbia.

HyperkalemiaECG=tall spiked T wave, prolongedQT intervial, widening QRS complexare all signs of hyperkalemia;

tumor lysis syndrome

hyperreactivity an abnormal condition in whichresponses to stimuli are exaggerated.

hyperresponsivenessexcessive or exaggerated response toa stimulus; in asthma leads tobronchoconstriction in response tophysical, chemical, or pharmacologicstimuli.

Hypertrophy Excessive devolopment.

hypocapnia low arterial carbon dioxide pressure(PaCO2 < 35 mm Hg); also calledhypocarbia.

Hypochondriac regions The upper lateral regions of theabdomen, beneath the ribs.

Hypoglossal (12th crainal nerve) difficulty chewing, talking andswallowing

hypokalemiapatients on diureticswill change patients normal ECG = Uwave is positive deflection followingthe T wave often present inhypokalemia

hypomagnesemiachronic alcholic

ie HR 160 BP 90/54 give IVmagnesium sulphate

prolonged QT intervial

If a health care provider is planning to transfuse apatient with a unit of packed red blood cells, which ofthe following solutions should the health careprovider hang with the transfusion? A. 5% dextrose in water B. 0.9% sodium chloride C. 5% dextrose in 0.9% sodium chloride D. 5%dextrose in lactated Ringer's solution

B. 0.9% sodium chloride The onlysolution appropriate for administrationwith whole blood or blood products is0.9% sodium chloride. The other optionsare not appropriate for use with bloodproducts.

If a nurse is assessing a patient whose recent blood gasdetermination indicated a pH of 7.32 and respirations aremeasured at 32 breaths/min, which of the following is the mostappropriate nursing assessment? A. The rapid breathing is causing the low pH. B. The nurse should sedate the patient to slow down respirations. C. The rapid breathing is an attempt to compensate for the low pH. D. The nurse should give the patient a paper bag to breathe into tocorrect the low pH.

C. The rapid breathing is an attempt to compensatefor the low pH. The respiratory system influences pH(acidity) through control of carbon dioxideexhalation. Thus, rapid breathing increases the pH.Breathing into a paper bag aids a patient who ishyperventilating; in respiratory alkalosis, it aids inlowering the pH. The use of sedation can causerespiratory depression and hypoventilation, resultingin an even lower pH.

If a nurse is caring for an 80-year-old patient with atemperature of 100.4 F, crackles at the right lungbase, pain with deep inspiration, and dyspnea, whichof the following orders is the nurse's priority? A.Sputum specimen for culture and sensitivity B. Codeine 15 mg orally every 6 hours as neededC. Incentive spirometer every 2 hours while awake D. Amoxicillin (Amoxil) 500 mg orally 4 times a day

A. Sputum specimen for culture and sensitivity The patient presentswith signs of a respiratory infection. To initiate the most effectivetherapy, the health care prescriber must know the pathogencausing the infection. Therefore, the sputum specimen is thenurse's priority. If the antibiotic is administered before thespecimen is obtained, the results of the culture might not be asaccurate and could impair the effectiveness of therapy. After thespecimen is obtained, the nurse can administer codeine forcoughing and begin the incentive spirometry to mobilize secretionsand improve the patient's ability to expectorate the secretions.

If a patient has pernicious anemia, the nurseshould provide information regarding A. frequent bouts of dyspnea. B. risks relative to dehydration. C. deficiency of intrinsic factor. D. lack of any effective treatment for thiscondition.

C. deficiency of intrinsic factor.Pernicious anemia is a type of anemiacaused by failure of absorption of vitaminB12 (cobalamin). The most commoncause is lack of intrinsic factor, aglucoprotein produced by the parietalcells of the gastric lining.

If a patient states, "It's hard for me to breathe and Ifeel short-winded all the time," what is the mostappropriate terminology to be applied indocumenting this assessment by a nurse? A. Apnea B. Dyspnea C. Tachypnea D. Respiratory fatigue

B. Dyspnea Dyspnea is a subjective description reflectiveof the patient's statement indicating difficulty inbreathing. Apnea refers to absence of breath or breathing.Tachypnea refers to an increased rate of breathing,usually greater than 20 breaths per minute. Respiratoryfatigue is subjective and usually refers to the patientexhibiting signs and symptoms associated with acomprehensive respiratory assessment including laboriousbreathing, use of accessory muscles, and slowing ofrespirations.

If a patient with an uncuffed tracheostomy tube coughsviolently during suctioning and dislodges thetracheostomy tube, a nurse should first A. call the physician. B. attempt to reinsert the tracheostomy tube. C. position the patient in a lateral position with the neckextended. D. cover the stoma with a sterile dressing and ventilatethe patient with a manual bag-mask until the physicianarrives.

B. attempt to reinsert the tracheostomytube.Retention sutures may be grasped (if present)and the tracheostomy opening spread, or a hemostatmay be used to spread the opening. The obturator isinserted into the replacement tube (one size smallerthan the original tube), lubricated with salinesolution, and inserted into the stoma at a 45-degreeangle to the neck. If the attempt is successful, theobturator tube should immediately be removed.

If a patient with arthritis develops iron-deficiency anemia, a nurse should askabout the patient's use of A. alcoholic beverages. B. stool softeners and laxatives. C. caffeinated foods and beverages. D. NSAIDs.

D. NSAIDs. NSAIDs decrease the level of vitamin C, which aids inthe absorption of iron. These drugs also compete with folate andvitamin K and may cause gastritis. Excessive alcoholic beverageconsumption can cause stomach irritation; alcohol would not bedirectly related to iron-deficiency anemia unless bleeding ulcers orgastritis were to occur. NSAID consumption, not stool softenersand laxative use, would be suspect for iron-deficiency anemia.Caffeinated foods and beverages can cause gastric irritation anddiscomfort but are not associated with iron-deficiency anemia.

If a patient with blood type O Rh- is given AB Rh- blood,the nurse would expect A. the patient's Rh factor to react with the RBCs of thedonor blood. B. no adverse reaction because the patient has noantibodies against the donor blood. C. the anti-A and anti-B antibodies in the patient's bloodto hemolyze the donor blood. D. the anti-A and anti-B antibodies in the donor blood tohemolyze the patient's blood.

C. the anti-A and anti-B antibodies in the patient's blood tohemolyze the donor blood. A patient with O Rh+ blood has no A orB antigens on the red cell but does have anti-A and anti-Bantibodies in the blood and has an Rh antigen. AB Rh- blood hasboth A and B antigens on the red cell but no Rh antigen and noanti-A or anti-B antibodies. If the AB Rh- blood is given to thepatient with O Rh+ blood, the antibodies in the patient's blood willreact with the antigens in the donor blood, causing hemolysis ofthe donor cells. There will be no Rh reaction because the donorblood has no Rh antigen.

In assessing an older client with dementia forsundowning syndrome, what assessment technique isbest for the nurse to use?

A. Observe for tiredness at the end of the day.B. Perform a neurologic exam and mental statusexam.C. Monitor for medication side effects.D. Assess for decreased gross motor movement.

A. Sundowning syndrome is a pattern ofagitated behavior in the evening, believedto be associated with tiredness at the endof the day combined with fewer orientingstimuli, such as activities andinteractions. (B, C, & D) with not provideinformation about this syndrome.

In older adults, infection after exposure to respiratory illness ismost likely to A. result in similar rates of infection as in the younger adult. B. be easily prevented with the use of antibiotics after beingexposed. C. result in serious lower respiratory infection related to weakenedrespiratory muscles and fewer cilia. D. be less serious because the older adult has less contact withyounger children who are most likely to carry serious infections.

C. result in serious lower respiratory infectionrelated to weakened respiratory muscles and fewercilia. Changes in the older adult respiratory systemmake older adults more susceptible to infections thatcan be very serious and life threatening. Use ofantibiotics to "prevent" lung infections is notrecommended and is ineffective for viral infections.

In preparing the preoperative teaching plan for apatient who is to undergo a total laryngectomy, anurse should give highest priority to the A. tracheostomy being in place for 2 to 3 days. B. patient's not being able to speak normally again. C. insertion of a gastrostomy feeding tube duringsurgery. D. patient's not being able to perform deep-breathingexercises.

B. patient's not being able to speak normally again. Patients whohave a total laryngectomy have a permanent tracheostomy and willneed to learn how to speak using alternative methods, such as anartificial larynx. The tracheostomy will be permanent to allownormal breathing patterns and air exchange. After surgery, thepatient's nutrition is supplemented with enteral feedings, andwhen the patient can swallow secretions, oral feedings can begin.Deep-breathing exercises should be performed with the patient atleast every 2 hours to prevent further pulmonary complications.

In teaching the patient with COPD about the need for physicalexercise, the nurse informs the patient that A. all patients with COPD should be able to increase walkinggradually up to 20 min/day. B. a bronchodilator inhaler should be used to relieve exercise-induced dyspnea immediately after exercise. C. shortness of breath is expected during exercise but should returnto baseline within 5 minutes after the exercise. D. monitoring the heart rate before and after exercise is the bestway to determine how much exercise can be tolerated.

C. shortness of breath is expected during exercise but should returnto baseline within 5 minutes after the exercise.Shortness of breathusually increases during exercise, but the activity is not beingoverdone if breathing returns to baseline within 5 minutes afterstopping. Bronchodilators can be administered 10 minutes beforeexercise but should not be administered for at least 5 minutes afteractivity to allow recovery. Patients are encouraged to walk 15 to 20minutes a day with gradual increases, but actual patterns willdepend on patient tolerance. Dyspnea most frequently limitsexercise and is a better indication of exercise tolerance than isheart rate in the patient with COPD.

In the case of pulmonary embolus from deep veinthrombosis, which of the following actions should thenurse 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 as tolerated and applyoxygen.

D. Sit the patient up in bed as tolerated andapply oxygen.The patient's clinical picture isconsistent with pulmonary embolus, and thefirst action the nurse takes should be toassist the patient. For this reason, the nurseshould sit the patient up as tolerated andapply oxygen before notifying the physician.

Ischemia Blood is held back from an area.

IV's infusions potential problemsmorphine, continous epidural =respiratory depressionmagnesium continous infusion =hypotensionvancomycin intermittent infusion =nephrotoxicity & phlebitits

jaundiceserium amylase & lipase 2 timeshigher than normal indicatepancreatic injuryfrothy tea colored urineclay colored stools complaints of puritis

Karyotype Picture of nuclear structures arrangedin numerical order.

kidney stone strain all urine most importantencourage urine

lactulose (Cephulac)reduce blood ammonia by excreation

of ammonia by stools

2 -3 soft stools per day

Laryngectomy cuff should be inflated only prior tofeeding

Laryngectomy Removal of the voice box.

Larynx Structure in the trachea.

Leukocyte Eosinophil is a (an)

levodopa (Sinemet)Parkinsons Diseaselessen tremorsincreases amount of levodopa to CNS(dopamine to the brain)s/s toxicity=dyskinesia,hallucinations, psychosis

Liver RUQ contain the _______.

lung abscess a pus-containing lesion of the lungparenchyma that results in a cavityformed by necrosis of lung tissue.

Lymphocyte A blood cell that produces antibodies.

Magnesium Sulphatehypomagnesemiareccomended for torsadesde pointes aform of polymorphic ventricaltackycardia associated with aprolonged QT intervial that occurswith hypomagnesemia

A male client who has never smoked but has hadCOPD for the past 5 years is now being assessed forcancer of the lung. The nurse knows that he is mostlikely to develop which type of lung cancer?

A. AdenocarcinomaB. Oat-cell carcinomaC. Malignant melanomaD. Squamous-cell carcinoma

A. is the only lung cancer not relatedto cigarette smoking related to lungscarring and fibrosis from preexistingpulmonary diseases such as TB andCOPD. (B& D) are related tosmoking. (C) is a skin cancer

A male client with arterial peripheral vasculardisease (PVD) complains of pain in his feet. Whichinstruction should the nurse give to the UPA toquickly relieve the client's pain?

A. Help the client to dangle his legs. 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 adependent position which can be achieved bydangling by improving blood flow and relieving pain.(B) is indicated for venous insufficiency and (C) isindicated for bed rest. (D) is indicated to facilitatecollateral circulation and may improve long termcomplaints of pain.

Malignant myeloma Tumor of bone marrow.

mechanical receptorsreceptors located in lungs, upperairways, chest wall, and diaphragmthat are stimulated by irritants,muscle stretching, and alveolar walldistortion.

Mediastinum The space in the chest between thelungs.

meniere syndrome (8th crainalnerve)

tinnitus, vertigo, eharing difficulties

Metabolism Sum of the chemical processes in acell.

metered-dose inhaler aerosolized drug delivered in aspecific amount by activating theinhaler or by inhaling.

methotrexate (Mexate)immunosuppressant

can cause bone marrow depressionrheumatoid arthritis

lab=hemaglobin decrease =adverseside effect

Mitochondria Part of a cell where catabolismprimarily occurs.

The most appropriate position to assist a patient with chronicobstructive pulmonary disease (COPD) who is having difficultybreathing would be a A. high Fowler's position without a pillow behind the head. B. semi-Fowler's position with a single pillow behind the head. C. right side-lying position with the head of the bed at 45 degrees'elevation. D. sitting upright and forward position with arms supported on anover-the-bed table.

D. sitting upright and forward position with armssupported on an over-the-bed table.Sitting uprightand leaning forward with arms supported on an over-the-bed table would be of most help to this patient,because it allows for expansion of the thoracic cage inall four directions (front, back, and two sides).

Myelogram X-ray record of the spinal cord.

nadolol (Corgard)

beta blockerdibilatating anginal painbypass surgery patientsuse with diuretic for hypertensionuse extreme caution with respiratoryproblems (asthma) and congestive heartfailure

nasal polypsbenign mucous membrane massesthat form slowly in response torepeated inflammation of the sinus ornasal mucosa and project into thenasal cavity.

Necr/o Death

neuro function altered neuro function =

neurogenic bladder infection - from stasis of urine andsubsuquent catheterization

NG Tube no drainage in 2 hoursclient nausated = reposition client onside

normocapnia normal arterial carbon dioxidepressure (PaCO2 35 to 45 mm Hg).

The nurse assesses a patient withshortness of breath for evidence of long-standing hypoxemia by inspecting:A. Chest excursion B. Spinal curvatures C. The respiratory patternD. The fingernail and its base

D. The fingernail and its base Clubbing, asign of long-standing hypoxemia, isevidenced by an increase in the anglebetween the base of the nail and thefingernail to 180 degrees or more, usuallyaccompanied by an increase in the depth,bulk, and sponginess of the end of the finger.

The nurse assesses a postoperative client. Oxygen is beingadministered at 2 L/min and a saline lock is in place.Assessment shows cool, pale, moist skin. The client is veryrestless 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 forhypovolemic shock and is exhibitingearly signs. Start IV to restore tissueperfusion. (A, C, D) are all importantbut less of a priority.

The nurse determines that a patient is experiencingcommon adverse effects from the inhaledcorticosteroid beclomethasone (Beclovent) afternoting which of the following? A. Adrenocortical dysfunction and hyperglycemia B. Elevation of blood glucose and calcium levelsC. Oropharyngeal candidiasis and hoarseness D. Hypertension and pulmonary edema

C. Oropharyngeal candidiasis and hoarsenessOropharyngeal candidiasis and hoarseness arecommon adverse effects from the use of inhaledcorticosteroids because the medication can lead toovergrowth of organisms and local irritation if thepatient does not rinse the mouth following each dose.

The nurse determines that the patient is notexperiencing adverse effects of albuterol (Proventil)after noting which of the following patient vitalsigns? 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 2-agonist that can sometimes cause adversecardiovascular effects. These wouldinclude tachycardia and angina. A pulserate of 76 indicates that the patient didnot experience tachycardia as an adverseeffect.

The nurse determines that the patient understood medicationinstructions about the use of a spacer device when taking inhaledmedications after hearing the patient state which of the followingas the primary benefit? A. "Now I will not need to breathe in as deeply when taking theinhaler medications." B. "This device will make it so much easier and faster to take myinhaled medications." C. "I will pay less for medication because it will last longer." D. "More of the medication will get down into my lungs to help mybreathing."

D. "More of the medication will getdown into my lungs to help mybreathing." A spacer assists moremedication to reach the lungs, withless being deposited in the mouthand the back of the throat.

A nurse establishes the presence of a tensionpneumothorax when assessment findings reveal a(n) A. absence of lung sounds on the affected side. B. inability to auscultate tracheal breath sounds. C. deviation of the trachea toward the side oppositethe pneumothorax. D. shift of the point of maximal impulse (PMI) to theleft, with bounding pulses.

C. deviation of the trachea toward the side oppositethe pneumothorax. Tension pneumothorax is causedby rapid accumulation of air in the pleural space,causing severely high intrapleural pressure. Thisresults in collapse of the lung, and the mediastinumshifts toward the unaffected side, which issubsequently compressed.

The nurse evaluates that a patient is experiencing theexpected beneficial effects of ipratropium (Atrovent)after noting which of the following assessmentfindings? A. Increased peak flow readings B. Increased level of consciousness C. Decreased sputum production D. Increased respiratory rate

A. Increased peak flow readings.Ipratropium is a bronchodilator that

should lead to increased PEFRs.

The nurse evaluates that discharge teaching for a patient hospitalizedwith pneumonia has been most effective when the patient states whichof the following measures to prevent a relapse? A. "I will increase my food intake to 2400 calories a day to keep myimmune system well." B. "I must use home oxygen therapy for 3 months and then will have achest x-ray to reevaluate." C. "I will seek immediate medical treatment for any upper respiratoryinfections." D. "I should continue to do deep-breathing and coughing exercises for atleast 6 weeks."

D. "I should continue to do deep-breathing and coughingexercises for at least 6 weeks." It is important for thepatient to continue with coughing and deep breathingexercises for 6 to 8 weeks until all of the infection hascleared from the lungs. A patient should seek medicaltreatment for upper respiratory infections that persist formore than 7 days. Increased fluid intake, not caloricintake, is required to liquefy secretions. Home O2 is not arequirement unless the patient's oxygenation saturation isbelow normal.

The nurse evaluates that nursing interventions topromote airway clearance in a patient admitted withCOPD are successful based on which of the followingfindings? A. Absence of dyspnea B. Improved mental status C. Effective and productive coughing D. PaO2 within normal range for the patient

C. Effective and productive coughingThe issue of the question is airwayclearance, which is most directlyevaluated as successful if the patientcan engage in effective andproductive coughing.

The nurse evaluates that teaching for the patient withiron deficiency anemia has been effective when thepatient states A. "I will need to take the iron supplementsthe rest of my life." B. "I will increase my dietary intake of milk and milkproducts." C. "I should increase my activity to increase my aerobiccapacity." D. "I should take the iron for several months after myblood is normal."

D. "I should take the iron for several months after myblood is normal." To replace the body's iron stores, ironsupplements should be continued for 2 to 3 months afterthe Hb level returns to normal, but if the cause of the irondeficiency is corrected, the supplements do not need to betaken for a lifetime. Milk and milk products are poorsources of dietary iron. Activity should be graduallyincreased as Hb levels return to normal because aerobiccapacity can be increased when adequate Hb is available.

The nurse identifies the nursing diagnosis of activityintolerance for a patient with asthma. The nurseassesses for which of the following etiologic factor forthis nursing diagnosis in patients with asthma? A. Anxiety and restlessness B. Effects of medications C. Fear of suffocation D. Work of breathing

D. Work of breathingWhen the patient doesnot have sufficient gas exchange to engage inactivity, the etiologic factor is often the workof breathing. When patients with asthma donot have effective respirations, they use allavailable energy to breathe and have littleleft over for purposeful activity.

The nurse is assessing a 75-year-old male client forsymptoms of hyperglycemia. Which symptom ofhyperglycemia is an older adult most likely toexhibit?

A. PolyuriaB. PolydipsiaC. Weight lossD. Infection

D. S/Sx of hyperglycemia in older adultsmay include fatigue, infection, andneuropathy (such as sensory changes).(A, B, C) are classic symptoms and maybe absent in the older adult.

The nurse is assessing a client who presents withjaundice. Which assessment finding is the mostsignificant indication that further follow up is needed?

A. Urine specific gravity of 1.03 with a urine output of500 ml in 8 hoursB. Frothy, tea-colored urineC. Clay-colored stools and complaints of pruritusD. Serum amylase and lipase levels that are twice theirnormal levels

D. Obstructive cholelithiasis andalcoholism are the two major causes ofpancreatitis, and an elevated serumamylase and lipase indicate pancreaticinjury. (A) is a normal finding. (B & C)are expected findings for jaundice.

The nurse is assigned to care for a patient in the emergencydepartment admitted with an exacerbation of asthma. The patienthas received a -adrenergic bronchodilator and supplementaloxygen. If the patient's condition does not improve, the nurseshould anticipate which of the following is likely to be the next stepin treatment? A. Pulmonary function testing B. Systemic corticosteroids C. Biofeedback therapy D. Intravenous fluids

B. Systemic corticosteroids Systemiccorticosteroids speed the resolution ofasthma exacerbations and areindicated if the initial response to the-adrenergic bronchodilator isinsufficient.

The nurse is assigned to care for a patient who hasanxiety and an exacerbation of asthma. Which of thefollowing is the primary reason for the nurse tocarefully inspect the chest wall of this patient? A. Observe for signs 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 musclesThe nurse physically inspects the chestwall to evaluate the use of intercostal(accessory) muscles, which gives anindication of the degree of respiratorydistress experienced by the patient.

The nurse is assisting a patient to learn self-administration ofbeclomethasone two puffs inhalation q6hr. The nurse explainsthat the best way to prevent oral infection while taking thismedication is to do which of the following as part of the self-administration techniques? A. Chew a hard candy before the first puff of medication. B. Ask for a breath mint following the second puff of medication. C. Rinse the mouth with water before each puff of medication. D. Rinse the mouth with water following the second puff ofmedication.

D. Rinse the mouth with water followingthe second puff of medication. Thepatient should rinse the mouth with waterfollowing the second puff of medicationto reduce the risk of fungal overgrowthand oral infection.

The nurse is caring for a 73-year-old patient who underwent a lefttotal knee arthroplasty. On the third postoperative day, the patientcomplains of shortness of breath, slight chest pain, and that"something is wrong." Temperature is 98.4o F, blood pressure130/88, respirations 36, and oxygen saturation 91% on room air.Which of the following should the nurse first suspect as theetiology 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 veinthrombosis The patient presents theclassic symptoms of pulmonary embolus:acute onset of symptoms, tachypnea,shortness of breath, and chest pain.

The nurse is caring for a client with a chest tube to waterseal drainage that was inserted 10 days ago because of aruptured bullae and pneumothorax. Which findingshould the nurse report to the healthcare provider beforethe chest tube is removed?A. Tidal of water in the water seal chamberB. Bilateral muffled breath sounds at basesC. Temperature of 101 degrees FD. Absence of chest tube drainage for 2 days.

A. Tidal in the water seal chamber shouldbe reported to the HPC to show that thechest tube is working properly. (B) mayindicate hypoventilation from the chesttube and usually improves when the tubeis removed. (C) indicates infection (D) isan expected finding.

The nurse is caring for a critically ill client with cirrhosisof the liver who has a nasogastric tube draining brightred blood. The nurse notes that the client's serumhemoglobin and hematocrit are decreased. Whatadditional change in lab data should the nurse expect?

A. Increased serum albumin B. Decreased serum creatinineC. Decreased serum ammoniaD. Increased liver function tests

C. The breakdown of glutamine in the intestine andthe increased activity of colonic bacteria from thedigestion of proteins increases the ammonia levels inthe clients with advanced liver disease, so removal ofblood, a protein source, from the intestines results inreduced ammonia. (A, B, D) will not be significantlyimpacted by the removal of blood.

The nurse is caring for a patient admitted to the hospitalwith pneumonia. Upon assessment, the nurse notes atemperature of 101.4 F, a productive cough with yellowsputum and a respiratory rate of 20. Which of thefollowing nursing diagnosis is most appropriate basedupon this assessment? A. Hyperthermia related toinfectious 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 Becausethe patient has spiked a temperature and has adiagnosis of pneumonia, the logical nursing diagnosisis hyperthermia related to infectious illness. There isno evidence of a chill, and her breathing pattern iswithin normal limits at 20 breaths per minute. Thereis no evidence of ineffective airway clearance fromthe information given because the patient isexpectorating sputum.

The nurse is caring for a patient who is to receive atransfusion of two units of packed red blood cells. Afterobtaining the first unit from the blood bank, the nursewould ask which of the following health team members inthe nurses' station to assist in checking the unit beforeadministration? A. Unit secretary B. Another registered nurse C. A physician's assistant D. A phlebotomist

B. Another registered nurseBeforehanging a transfusion, the registerednurse must check the unit withanother RN or with a licensedpractical (vocational) nurse,depending on agency policy.

The nurse is caring for a patient with an acuteexacerbation of asthma. Following initial treatment,which of the following findings indicates to the nursethat the patient's respiratory status is improving? A. Wheezing becomes louder B. Vesicular breath sounds decrease C. Aerosol bronchodilators stimulate coughing D. The cough remains nonproductive

A. Wheezing becomes louder Theprimary problem during an exacerbationof asthma is narrowing of the airway andsubsequent diminished air exchange. Asthe airways begin to dilate, wheezing getslouder because of better air exchange.

The nurse is caring for a patient with COPD andpneumonia who has an order for arterial blood gasesto be drawn. Which of the following is the minimumlength of time the nurse should plan to hold pressureon the puncture site? A. 2 minutes B. 5 minutes C. 10 minutes D. 15 minutes

B. 5 minutes Following obtaining an arterial bloodgas, the nurse should hold pressure on the puncturesite for 5 minutes by the clock to be sure thatbleeding has stopped. An artery is an elastic vesselunder higher pressure than veins, and significantblood loss or hematoma formation could occur if thetime is insufficient.

The nurse is caring for a postoperative patient with sudden onset ofrespiratory distress. The physician orders a STAT ventilation-perfusion scan. Which of the following explanations should thenurse provide to the patient about the procedure? A. This test involves injection of a radioisotope to outline the bloodvessels in the lungs, followed by inhalation of a radioisotope gas. B. This test will use special technology to examine cross sections ofthe chest with use of a contrast dye. C. This test will use magnetic fields to produce images of the lungsand chest. D. This test involves injecting contrast dye into a bloodvessel to outline the blood vessels of the lungs.

A. This test involves injection of a radioisotope tooutline the blood vessels in the lungs, followed byinhalation of a radioisotope gas.A ventilation-perfusion scan has two parts. In the perfusionportion, a radioisotope is injected into the blood andthe pulmonary vasculature is outlined. In theventilation part, the patient inhales a radioactive gasthat outlines the alveoli.

The nurse is completing an admission inter for a client withParkinson disease. Which question will provide additioninformation 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 blackout spells?"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 frequentlyexperience difficulty in initiating,maintaining, and performing motoractivities. They may even experiencebeing rooted, unable to move. (A, B, D)Does not typically occur in Parkinson.

The nurse is evaluating whether a patient understandshow to safely determine whether a metered dose inhaleris empty. The nurse interprets that the patientunderstands this important information to preventmedication underdosing when the patient describeswhich method to check the inhaler? A. Place it in water to see if it floats. B. Shake the canister while holding it next to the ear. C. Check the indicator line on the side of the canister. D. Keep track of the number of inhalations used.

D. Keep track of the number of inhalations used. It isno longer appropriate to see if a canister floats inwater or not as research has demonstrated this is notaccurate. The best method to determine when toreplace an inhaler is by knowing the maximum puffsavailable per MDI and then replacing when thoseinhalations have been used.

The nurse is interviewing a client who is takinginterferon-alfa-2a (Roferon-A) and ribavirin (Virazole)combination therapy for hepatitis C. The client reportsexperiencing overwhelming feelings of depression. Whataction should the nurse implement first?

A. Recommend mental health counseling.B. Review the medications actions and interactions.C. Assess for the client's daily activity level.D. Provide information regarding a support group.

B. Alpha-interferon and ribavirincombination therapy can causesevere depression. (A, B, C) may beimplemented after physiologicalaspect of the situation are assessed.

The nurse is observing an unlicensed assistive personnel(UPA) who is performing morning care for a bedfastclient with Huntington disease. Which care measure ismost important for the nurse to supervise?

A. Oral careB. BathingC. Foot careD. Catheter care

A. A client with Huntington diseaseexperiences problems with motorskills such as swallowing and is athigh risk for aspiration. (B, C, D) donot pose life-threateningconsequences.

A nurse is performing assessment for a patientdiagnosed with chronic obstructive pulmonarydisease (COPD). Which of the following findingsshould the nurse expect to observe? A. Nonproductive cough B. Prolonged inspiration C. Vesicular breath sounds D. Increased anterior-posterior chest diameter

D. Increased anterior-posterior chest diameter Anincreased anterior-posterior diameter is a compensatorymechanism experienced by patients with COPD and iscaused by air-trapping. Patients with COPD have aproductive cough, often expectorating copious amountsof sputum. Because of air-trapping, patients with COPDexperience a prolonged expiration because the rate of gason exhalation takes longer to escape. Chest auscultationfor patients with COPD often reveals wheezing, crackles,and other adventitious breath sounds.

The nurse is performing hourly neurological check for aclient with a head injury. Which new assessment findingwarrants the most immediate intervention by the nurse?

A. A unilateral pupil that is dilated and nonreactive tolight.B. Client cries out when awakened by a verbal stimulus.C. Client demonstrates a loss of memory to the eventsleading up to the injury.D. Onset of nausea, headache, and vertigo.

A. Any changes in pupil size andreactivity is an indication of increasingICP and should be reported immediately.(B) is normal for being awakened. (C &D) are common manifestations of headinjury and less of an immediacy than (A).

The nurse is planning the care for a client who is admitted with thesyndrome of inappropriate antidiuretic hormone secretion(SIADH). Which interventions should the nurse include in thisclient's plan of care? (Select all that apply.)

A. Salt-free dietB. Quiet environmentC. Deep tendon reflex assessmentsD. Neurologic checksE. Daily weightsF. 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 areless than 115 mEq/L. The nurse should maintain a quietenvironment (B) to prevent overstimulation that can lead to periodsof disorientation, assess deep tendon reflexes (C) and neurologicchecks (D) to monitor for neurologic deterioration. Daily weights(E) should be monitored to assess for fluid overload: 1 kg weightgain equals 1 L of fluid retention, which further dilutes serumsodium levels. (A and F) contribute to dilutional hyponatremia.

A nurse is preparing to establish oxygen therapy for a patient withCOPD, and the physician's prescription reads "oxygen per nasalcannula at 5 L per minute." Which of the following actions shouldthe nurse take? A. Administer the oxygen as prescribed. B. Call the physician andquestion the correct flow rate of the oxygen. C. Establish the oxygen as prescribed and obtain an ABG. D. Change the delivery device from a nasal cannula to a simpleoxygen mask.

B. Call the physician and question the correct flow rate of the oxygen.The nurse should call the physician immediately and question the flowrate for delivery of the oxygen before implementation. Oxygen is usedcautiously in patients with COPD because of longstanding hypoxemiaserving as the respiratory drive mechanism. If high levels of oxygen areadministered, the respiratory drive can be obliterated. Changing thedevice to a simple oxygen mask may alter the oxygen concentrationbeing delivered to the patient and will further enhance the obliterationof the patient's respiratory drive. Obtaining an ABG sample is not apriority at this time, and the action does not address the validity of theprescribed oxygen dosing for the patient.

A nurse is providing care to an adult female patientand observes that the Hb laboratory analysis result is9 g/dl. Based on this finding, the nurse should expectto observe A. dyspnea. B. bradycardia. C. warm, dry skin. D. activity tolerance without complaint of fatigue.

A. dyspnea.Hb levels are used to determine the severity of anemia.Patients with moderate anemia (Hb 6 to 10 g/dL) may suffer fromdyspnea, palpitations, diaphoresis with exertion, and chronicfatigue. Patients who are anemic usually have cool skin related tocompensatory mechanism of mild vasoconstriction. Patients whoare anemic experience tachycardia because of increased demandsplaced on the heart to meet overall metabolic requirements. Activitytolerance without complaint is not correct because patients withanemic conditions fatigue readily.

A nurse is reviewing the hematologic test results fora patient in whom the hematocrit (Hct) is reported ata reading of 30%. Based on this result, the nurseshould interpret that the patient A. is susceptible to bleeding disorders. B. has fewer red blood cells than normal. C. isexperiencing an inflammatory response. D. is experiencing an acute hemolytic crisis.

B. has fewer red blood cells than normal.The Hct is the measure ofthe volume of red blood cells in whole blood expressed as apercentage. This test is useful in the diagnosis of anemia,polycythemia, and abnormal hydration states. Patients who aresusceptible to bleeding disorders likely will have a low plateletcount. The inflammatory response may best be evaluated byexamination of results that include the white blood cell count withdifferential analysis. Acute hemolytic crisis develops in patientsreceiving blood components in which incompatibility occurs or inpatients with bleeding disorders or conditions that promote cellulardamage, such as damage associated with shock.

The nurse is reviewing the routine medications taken by a clientwith chronic angle closure glaucoma. Which medicationprescription 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 of sedation.D. A corticosteroid with a side effect of hyperglycemia.

B. Clients with angle closure glaucomashould not take medications that dilatethe pupil (B) because this can precipitateacute and severely increased intraocularpressure. (A, C, D) do not causeincreased intraocular pressure, which isthe primary concern.

The nurse is scheduled to give a dose of ipratropiumbromide by metered dose inhaler. The nurse wouldadminister the right drug by selecting the inhalerwith which of the following trade names? A. Vanceril B. Pulmicort C. AeroBid D. Atrovent

D. Atrovent The trade or brand namefor ipratropium bromide, an

anticholinergic medication, isAtrovent.

The nurse is scheduled to give a dose of salmeterol bymetered dose inhaler (MDI). The nurse wouldadminister the right drug by selecting the inhalerwith which of the following trade names? A. Vanceril B. Serevent C. AeroBid D. Atrovent

B. Serevent The trade or brand namefor salmeterol, an adrenergicbronchodilator, is Serevent.

The nurse is teaching a patient how to self-administer ipratropium(Atrovent) via a metered dose inhaler. Which of the followinginstructions given by the nurse is most appropriate to help thepatient learn proper inhalation technique? A. "Avoid shaking the inhaler before use." B. "Breathe out slowlybefore positioning the inhaler." C. "After taking a puff, hold the breath for 30 seconds beforeexhaling." D. "Using a spacer should be avoided for this type of medication."

B. "Breathe out slowly before positioningthe inhaler." It is important to breatheout slowly before positioning the inhaler.This allows the patient to take a deeperbreath while inhaling the medication thusenhancing the effectiveness of the dose.

The nurse is teaching a patient who is to undergo bone marrowaspiration. Which of the following statements made by the nursewould indicate correct instruction regarding the site for theaspiration procedure? A. "The health care provider will perform the aspiration by needleto the femur." B. "The health care provider will perform the aspiration by needleto the scapula." C. "The health care provider will perform theaspiration by needle to the antecubital fossa." D. "The health care provider will perform the aspiration by needleto the posterior iliac crest."

D. "The health care provider will perform theaspiration by needle to the posterior iliac crest."Bone marrow samples are commonly taken from theposterior iliac crest or, as an alternative, the sternummay be aspirated. These sites provide relative ease inaccessing the bone marrow via the biopsy needle. Theantecubital fossa, femur, and scapula do not allowaccess to bone marrow while also providing reducedrisk of harm to the patient.

A nurse is working on a respiratory care unit where manyof the patients are affected by asthma. Which of thefollowing actions by the nurse would most likely increaserespiratory difficulty for the patients? A. Wearing perfume to work B. Encouraging patients to ambulate daily C. Allowingthe patients to eat green leafy vegetables D. Withholding antibiotic therapy until cultures areobtained

A. Wearing perfume to work People with asthma should avoid extrinsicallergens and irritants (e.g., dust, pollen, smoke, certain foods, colognesand perfumes, certain types of medications) because their airwaysbecome inflamed, producing shortness of breath, chest tightness, andwheezing. Many green leafy vegetables are rich in vitamins, minerals,and proteins, which incorporate healthy lifestyle patterns into thepatients' daily living routines. Routine exercise is a part of a prudentlifestyle, and for patients with asthma the physical and psychosocialeffects of ambulation can incorporate feelings of well-being, strength,and enhancement of physical endurance. Antibiotic therapy is alwaysinitiated after cultures are obtained so that the sensitivity to theorganism can be readily identified.

The nurse know that a client taking diuretics must beassessed for the development of hypokalemia, and thathypokalemia will create changes in the client's normalECG tracing. Which ECG change would be an expectedfinding in the client with hypokalemia?

A. Tall, spiked T wavesB. A prolonged QT intervalC. A widening QRS complexD. Presence of a U wave

D. A U wave is a positive deflectionfollowing the T wave and is oftenpresent with hypokalemia. A, B, Cindicate hyperkalemia.

The nurse know that normal lab values expected for an adult may vary in anolder client. Which data would the nurse expect to find when reviewinglaboratory values of an 80-year-old man who is in good overall health.

A. Complet blood count reveals increased WBC and decreased RBC counts.B. Chemistries reveal an increased serum bilirubin with slightly increased liverenzymes.C. Urinalysis reveals slight protein in the urine and bacteriuria with pyuria.D. Serum electrolytes reveal a decreased sodium level with an increasedpotassium level.

C. In older adults the protein found inurine is slightly risen as a result of kidneychanges or subclinical UTIs and theclient frequently experiencesasymptomatic bacteriuria and pyuria as aresult of incomplete bladder emptying.(A, B, D) are not normal findings.

The nurse notes a physician's order written at 10:00 AMfor 2 units of packed red blood cells to be administered toa patient who is anemic secondary to chronic blood loss.If the transfusion is picked up at 11:30, the nurse shouldplan to hang the unit no later than which of the followingtimes? A. 11:45 AM B. 12:00 noon C. 12:30 PM D. 3:30 PM

B. 12:00 noon The nurse must hangthe unit of packed red blood cellswithin 30 minutes of signing themout from the blood bank

The nurse notices clear nasal drainage in a patientnewly admitted with facial trauma, including a nasalfracture. 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 isnormal.

A. test the drainage for the presence ofglucose. Clear nasal drainage suggestsleakage of cerebrospinal fluid (CSF). Thedrainage should be tested for thepresence of glucose, which wouldindicate the presence of CSF.

The nurse observes ventricular fibrillation ontelemetry and upon entering the clients bathroomfinds the client unconscious on the floor. Whatintervention should the nurse implement first?

A. Administer an antidysrhythmic medication.B. Start cardiopulmonary resuscitation.C. Defibrillate the client at 200 joules.D. Assess the client's pulse oximetry.

B. Ventricular fibrillation is a life-threatening dysrhythmia and CPRshould be started immediately. A & Care appropriate but B is the priority.D does not address the seriousness ofthe situation.

The nurse plans to help an 18-year-old developmentally disabled female clientambulate on the first postoperative day. When the nurse tells her it is time toget out of bed, the client becomes angry and yells at the nurse. "Get out ofhere! I'll get up when I'm ready." Which response should the nurse provide?

A. "Your healthcare provider has prescribed ambulation on the firstpostoperative day."B. "You must ambulate to avoid serious complications that are much morepainful."C. "I know how you feel; you're angry about having to do this, but it isrequired."D. "I'll be back in 30 minutes to help you get out of bed and walk around theroom."

D. Returning in 30 minutes provides acooling off period, is firm, direct,nonthreatening, and avoids argumentwith the client. B is threatening. C.assumes what the client is feeling. A.avoids the nurse's responsibility toambulate the client.

The nurse receives a physician's order to transfuse fresh frozen plasma to apatient suffering from an acute blood loss. Which of the following proceduresis most appropriate for infusing this blood product? A. Hand the fresh frozen plasma as a piggyback to a new bag of primary IVsolution without KCl. B. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. C. Hang the fresh frozen plasma as a piggyback to the primary IV solution. D. Infuse the fresh frozen plasma as a piggyback to a primary solution ofnormal saline.

B. Infuse the fresh frozen plasma as rapidly as thepatient will tolerate. The fresh frozen plasma shouldbe administered as rapidly as possible and should beused within 2 hours of thawing. Fresh frozen plasmais infused using any straight-line infusion set. Anyexisting IV should be interrupted while the freshfrozen plasma is infused, unless a second IV line hasbeen started for the transfusion.

The nurse reviews pursed lip breathing with a patient newly diagnosedwith emphysema. The nurse reinforces that this technique will assistrespiration by which of the following mechanisms? A. Preventing bronchial collapse and air trapping in the lungs duringexhalation B. Increasing the res