PN2 NUR2571pn2 exam 1 questions & answers latest update 2021/2022., Exams of Nursing

Download PN2 NUR2571pn2 exam 1 questions & answers latest update 2021/2022. and more Exams Nursing in PDF only on Docsity! 4. Aclient has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? b. Measure and compare cuff pressures. ANS: B 2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? c. Client has reduced breath Sounds. Nurse calls physician ANS: C 3. A nurse assesses a clients respiratory status. Which information is of highest priority for the nurse to obtain? d. Qecuation and ANS: D 2.A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first? a. Cardiac rate and rhythm ANS: A 6.A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next? a. Assess clients rate, rhythm, and depth of respiration, 7. A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action? b. Absent breath sounds ANS: B 8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first? a. Apply oxygen by mask or nasal cannula. 8. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure? d. Validate that informed consent has been given by the client. ANS: D 9. A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? d. The trachea is deviated toward the opposite side of the neck. ANS: D 1.A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? b. Ensure an x-ray is completed to confirm Placement. ANS: B 3.A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching? a. Avoid carrying your grandchild with the arm that has the central catheter. ANS: A 5.A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? b. Report of headache and stif f neck ANS: B 7.A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? a. Upper extremity swelling is feted! ANS: D 13.A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching? ee 12. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive? 5. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? c. A 55-year-old woman who is 50 pounds overweight ANS: C 7. A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first? ANS: A 2.A client is prescribed 250 mL of normal saline to infuse over 4 hours via gravity. The facility supplies gravity tubing with a drip factor of 15 drops/mL. At what rate (drops/min) should the nurse set the infusion to 1.A client is prescribed 1000 mL of normal saline to infuse over 24 hours. At what rate should the nurse set the pump (mL/hr) to deliver this infusion? (Record your answer using a whole number.) mL/hr ANS:42--1000 mL 24 hours = 41.6 mL/hr (42 is the answer) 12. A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, How will this medication help me? How should the nurse respond? c. This medication will promote daytime wakefulness. ANS: C 2. A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.) b. Hypertension c. Leukemia d. Cocaine use ANS: B, c,D 3. After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the clients understanding. Which statement indicates the client comprehends the teaching? c. | will take this medication every morning to help prevent an acute attack. ANS: C 9. A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this clients teaching? c. Eat a well-balanced, nutritious diet. ANS: C 10. While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? b. Cover the insertion site with sterile gauze. ANS: B 13. A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take? d. Administer pain medication and encourage the client to take deep breaths. ANS: D 14. A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax? d. When the tube becomes disconnected from the drainage system ANS: D 17. The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, The medication is too expensive to use every day. | only use my inhaler when | have an attack. How should the nurse respond? d. It is important to use this type of inhaler every day. Lets identify potential community services to help you. ANS: D 5. A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) b. Tracheal deviation c. Sudden onset of shortness of breath ANS: B, C 8. A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met? | 10. A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next? 8.A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen ANS: A 12.A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? c. | will take this medication on an empty stomach. ANS: C 3. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the clients oxygen saturation. ANS: A 15.A client has been hospitalized with tuberculosis (TB). The clients spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. ANS: A 16.A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a Visiting Nurses for directly observed therapy ANS: D 15.A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client? ANS: D 4. A nurse has conducted a community screening event for oral cancer. What client is the highest priority for referral to a dentist? b. Client who smokes and drinks daily ANS: B 6. A client is having a temporary tracheostomy placed during surgery for oral cancer. What action by the nurse is best to relieve anxiety? a. Agree on a postoperative communication method. ANS: A 9. Aclient had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is the priority? c. Place the client in a high-Fowlers position. ANS: C 2. A nurse studying cancer knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.) a. Coal miner c. Metal worker d. Plumber e. Textile worker ANS: A, c,D,E 8.A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up into the lower part of the clients neck. What action by the nurse takes priority? a. Assess the clients oxygenation: ANS: A 6.A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods should the nurse include in the teaching? (Select all that apply.) a. c. d. e. Tomato sauce ANS: A, C, D, E 12. A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning ANS: A 15. A client at risk for developing hyperkalemia states, | love fruit and usually eat it every day, but now! cant because of my high potassium level. How should the nurse respond? c. Berries, cherries, apples, and peaches are low in potassium. ANS: C 11. A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first? c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. ANS: C 14. After teaching a client to increase dietary potassium intake, a nurse assesses the clients understanding. Which dietary meal selection indicates the client correctly understands the teaching? c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk ANS: C 4. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.) a. Electrocardiogram changes d. Paralytic ileus e. Skeletal muscle weakness ANS: A, D, E 1. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism? 13. A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first? and depth. ANS: A 6. After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all that apply.) c. Strong productive cough d. Active bowel sounds ANS: C, D 7. A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.) b. Use a draw sheet to reposition the client in bed. d. Provide nonslip footwear for the client to use when out of bed. ANS: B, D 3. A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy? d. Metabolic alkalosis ANS: D 4. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take? d. Teach the client fall prevention measures. ANS: D 9. A client presents to the emergency department reporting severe abdominal pain. On assessment, the nurse finds a bulging, pulsating mass in the abdomen. What action by the nurse is the priority? b. Notify the provider immediately. ANS: B 10. A nurse assesses a clients oral cavity and observes the condition depicted in the photo below: What action by the nurse is best? b. Assess ANS: B 14. A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? d. Assess the clients bowel sounds. ANS: D b. Alanine aminotransferase (ALT): 180 U/L ANS: B 18.A client has the diagnosis of valley fever accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on? a Oral fluconazole (Difluean) ANS: D 7. Anurse is caring for four clients. After receiving the hand-off report, which client should the nurse see first? b. Client who had a tracheostomy 4 hours ago and needs frequent suctioning ANS: B 4.A client with an esophageal tumor has difficulty swallowing and has been working with a speech-language pathologist. What assessment finding by the nurse indicates that the priority goal for this problem is being met? b. Lungs clear after meals and snacks ANS: B 13.A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first? c. Client who had an esophagectomy with a respiratory rate of 32/min ANS: C 11. A nurse cares for a client who states, My husband is repulsed by my colostomy and refuses to be intimate with me. How should the nurse respond? a. Lets talk to the ostomy nurse to help you and your husband work through this. ANS: A 16. A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, The stool in my pouch is still liquid. How should the nurse respond? a. The stool will always be liquid with this type of colostomy. ANS: A 20.A client is admitted with suspected pneumonia from the emergency department. The client went to the primary care provider a few days ago and shows the nurse the results of what the client calls an allergy test, as shown below: What action by the nurse takes priority? Cc. Precautions: ANS: C 3.A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) b. c seconds ANS: B, C 18.A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Based on the information provided, which action should the nurse take? b. Administer the prescribed medication, ANS: B 4. A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity d. Range of motion e. Vision ANS: A, B, D, E 1. The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.) S:A,B,C,D 21.A nurse admits a client from the emergency department. Client data are listed below: History/70 years of age/ History of diabetes/ On insulin twice a day/ Reports new-onset dyspnea and productive cough/ What action by the nurse is the priority? 3. A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The clients blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate? 12. A nurse assesses a client with Crohns disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? 13. A nurse reviews the chart of a client who has Crohns disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. 19. A nurse plans care for a client with Crohns disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this clients plan of care? >