DOUBLE TROUBLE
These infectious conditions require droplet precautions in a healthcare setting.Select all that apply
a.)Clostridium difficile
b.)Pertussis
c.)Tuberculosis
d.)Rhinovirus
e.)Chickenpox
What are pertussis and rhinovirus?
What factors can cause hypertension? Select all that apply
A. Smoking
B. Active lifestyle
C. Obesity
D. Postmenopausal females
E. White American ethnicity
What are Smoking, obesity, and postmenopausal females?
Which of the following describes a client safety event?
a. An unexpected event or circumstance that occurred with or without injury to the client but that had the potential to cause harm to the client.
b. A potential error or event or circumstance that could have caused harm but that was caught and avoided.
c. A situation or circumstance that caused unexpected harm to the client.
d. A critical, unexpected adverse event that causes severe physical or psychological harm to a client, including death, dismemberment, permanent injury, and severe or temporary injury .
what is An unexpected event or circumstance that occurred with or without injury to the client but that had the potential to cause harm to the client?
Which of the following accurately describes inspiratory reserve volume?
a. Volume of air inspired and expired with each breath.
b. Volume of air remaining in the alveoli after expiration.
c. Volume of air breathed in after a typical inspiration.
d. Volume of air remaining in the lung after maximal inspiration.
what is Volume of air breathed in after a typical inspiration?
A nurse is preparing to take an oral temperature on an adult client. Which of the following actions should the nurse take?
A. Place the probe under the tongue in the anterior portion
B. Take the temperature immediately after the client drinks iced water
C. Ask the client to keep their lips closed around the probe
D. Insert the probe 2–3 cm toward the umbilicus
what is Asking the client to keep their lips closed around the probe?
Which statement best describes the relationship between ventilation and perfusion?
A. Ventilation refers to blood flow, and perfusion refers to air movement in the lungs
B. Ventilation is the movement of air in and out of the alveoli, while perfusion is the flow of blood through pulmonary capillaries
C. Ventilation and perfusion both refer to oxygen transport by hemoglobin
D. Ventilation occurs only during inhalation, while perfusion occurs only during exhalation
What is Ventilation is the movement of air in and out of the alveoli, while perfusion is the flow of blood through pulmonary capillaries?
Which findings correctly define Myoclonus?
a. Alteration in muscle movement as continuous, rapid twitching of a muscle at rest.
b. Alteration in muscle tone manifested as resistance to any manipulation of the joint.
c. Alteration in muscle movement by opposing muscle groups that results in a rhythmic movement of one or more joints.
d. Alteration in muscle movement that is seen as a sudden jerking of muscle.
what is Alteration in muscle movement that is seen as a sudden jerking of muscle?
Which of the following are disadvantages of using a simple face mask?
a. A good seal is required around the face to ensure effectiveness of the mask and the amount of oxygen inspired
b. Headaches and dry mucous membranes can occur if the flow greater than 4 L/min
c. Not recommended for clients at risk for CO2 retention
d. Not to be used with humidification
what is Not recommended for clients at risk for CO2 retention?
Which of the following describes the sensation of bubbles under the skin that indicates air has become trapped in the layers beneath the skin?
a. Tactile fremitus
b. Crepitus
c. Subcutaneous emphysema
d. Joint cavitation
what is Crepitus?
A nurse is caring for a client with COPD who is experiencing shortness of breath and using accessory muscles to breathe. Which of the following interventions should the nurse implement first?
A. Encourage the client to perform pursed‑lip breathing
B. Increase oxygen to 6 L/min via nasal cannula
C. Instruct the client to lie flat in bed
D. Obtain a sputum specimen
what is Encouraging the client to perform pursed‑lip breathing?
Which of the following is not a goal of the National Patient Safety Goals?
A. Improve staff communication of critical results
B. Use two client identifiers before procedures
C. Increase bedside nursing time to 70%
D. Prevent hospital-acquired infections through hand hygiene
What is Increasing bedside nursing time to 70%?
What type of transmission precautions should be taken for Clostridioides difficile?
a. Surgical masks
b. Gown and gloves
c. Negative pressure chamber
d. Mask and gloves
what are Gown and gloves?
What is the expected respiratory rate for a 5 year old preschooler?
a. 16 to 20/min
b. 20 to 25/min
c. 12 to 20/min
d. 25 to 30/min
what is 20 to 25/min?
Which of the following best describes stridor?
a. Caused by fluid filling the air sacs that sound like music or a whistling noise heard on exhalation.
b. A high-pitched noise creating a whistling sound due to air going through narrowed airways.
c. Obstruction of the airway that sounds like rattling.
d.Narrowing of the airway heard on inhalation that sounds like music or whistling.
what is Narrowing of the airway heard on inhalation that sounds like music or whistling?
A nurse is assessing a client with suspected respiratory distress. Which of the following findings should the nurse recognize as an unexpected assessment finding?
A. Symmetrical thorax
B. Vesicular breath sounds in peripheral lung fields
C. Intercostal retractions
D. Relaxed, comfortable breathing
what is Intercostal retractions?
What is a clinical manifestation for a patient with a fever?
A. Bradycardia
B. Hypothermia
C. Diaphoresis
D. Decreased metabolic rate
What is Diaphoresis?
What is the safest way to avoid needlestick injury?
a. Recapping needles
b. Disposing in biohazard bag
c. Ensuring sharps box is 2/4 full
d. Engage needle safety device
whats is Engage needle safety device?
Which of the following best describe Kussmaul respirations?
a. Respirations are irregular and consist of a cycling pattern of breaths ranging from shallow to deep
b. Regular in rhythm, but abnormally deep and rapid.
c. A cessation of respirations occurring due to opioid toxicity, trauma, or neurologic dysfunction.
d. Respiratory rate that is lower than the expected reference range.
what is Regular in rhythm, but abnormally deep and rapid?
How much sputum should the nurse encourage the client to cough up for a sputum specimen collection?
a. 1 tablespoon
b. 2-3 teaspoons
c. 1-2 teaspoons
d. At least 2 teaspoons
what is 1-2 teaspoons?
A nurse is preparing to teach a client how to use an incentive spirometer. Which of the following instructions should the nurse include?
A. Exhale forcefully into the mouthpiece
B. Hold each breath for 3–5 seconds after inhaling
C. Perform 3 repetitions per hour
D. Keep lips loosely around the mouthpiece
what is Hold each breath for 3–5 seconds after inhaling?
A nurse is preparing a room for a client diagnosed with Tuberculosis. Which of the following interventions are appropriate? Select all that apply.
a. Place the client in a negative-pressure room
b. Require healthcare workers to wear an N95 respirator when in the room
c. Keep the client’s door closed at all times
d. Require visitors to wear a gown, gloves, and a surgical mask
e. Require the client to wear a surgical mask during transport outside of the room
what are A,B,C,E ?
A nurse is assessing a client and hears a high-pitched, harsh sound during inspiration. Which condition should the nurse suspect?
A. Asthma
B. Pneumonia
C. Upper airway obstruction
D. Chronic obstructive pulmonary disease
WHAT IS Upper airway obstruction?
A nurse is collecting data during an initial assessment. Which of the following is considered objective data?
A. “I feel short of breath when I walk.”
B. “My pain is a 7 out of 10.”
C. Respiratory rate of 28 breaths/min
D. “I feel anxious about my condition.”
WHAT IS Respiratory rate of 28 breaths/min?
A nurse is assessing a client and notes rapid, deep breathing. Laboratory values for this client are: pH-7.48, PaCO- 32 mmHg, PaO 95 mmHg. Which acid-base imbalance should the nurse identify?
A. Metabolic acidosis
B. Respiratory acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
WHAT IS Respiratory alkalosis?
A client is being discharged on several new medications. Which nursing action is MOST important during discharge medication reconciliation.
A. Give the client a list of medications to take home
B. Compare home medications with newly prescribed medications to prevent omission, duplication, and interactions
C. Tell the client to stop all old medications
D. Assume the client understands all medications
WHAT IS Comparing home medications with newly prescribed medications to prevent omission, duplication, and interactions?