Oxygenation
A nurse is teaching a postoperative patient about measures to prevent pneumonia. The patient has significant pain from a thoracic incision. Which intervention is the highest priority for preventing atelectasis and pneumonia in this patient?
A. Using chest physiotherapy
B. maintaining hydration
c. administers guaifenesin to mobilize mucus
D. Ensuring pain management
D. Ensuring pain management
A HCP prescribes a medication that must be administered via the intramuscular route. which site should the nurse eliminate from consideration because it has the highest potential for injury when administering a IM injection?
A. Vastus lateralis
B. Rectus femoris
C. Ventrogluteal
D. Dorsogluteal
D. Dorsogluteal
If an IV has become infiltrated, the nurse will observe which of the following assessment findings?
a. Pallor, pain
b. Erythema, warmth
c. Erythema, swelling
d. Warmth, swelling
C. Erythema, swelling
Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats per minute. The nurse would document this difference as which of the following?
a. Pulse deficit
b. Pulse amplitude
c. Ventricular rhythm
d. Heart arrhythmia
a. Pulse deficit
The nurse is admitting a patient to the operating room. Which of the following nursing actions should be given the highest priority by the nurse?
A. Assessing the patient’s level of consciousness.
B. Checking the patient’s vital signs.
C. Checking the patient’s identification and correct operative permit.
D. Positioning and performing skin preparation to the patient.
C. Checking the patient’s identification and correct operative permit
Proper patient identification and verification of the surgical permit are the highest priorities when admitting a patient to the operating room. This prevents wrong-patient, wrong-site, or wrong-procedure errors, which are considered never events in healthcare. The nurse must confirm the patient’s identity, surgical site, and procedure with the surgical team before proceeding.
A patient is admitted with acute pulmonary edema and is expectorating large amounts of sputum. What color and consistency would the nurse anticipate the sputum to be?
A. Rust- colored
B. Yellow/ green and thick
C. White and clear
D. Pink and frothy
D. Pink and frothy
im not adding a rationale yall should know this :|
The nurse is preparing 10 units of regular insulin and 5 units of NPH insulin. Which of the following statements is the most accurate?
A. The NPH insulin is the shortest acting form of insulin.
B. Air is injected first into the regular insulin, then into the NPH.
C. The insulin vial should be discarded if there are any bubbles in it.
D. This medication order is given via the subcutaneous route.
D. This medication order is given via the subcutaneous route.
A patient has undergone a thyroidectomy. Which of the following are the earliest signs of poor tissue perfusion and respiratory distress?
A. Cyanosis, lethargy.
B. Fast, thready pulse, bradypnea
C. Apprehension and restlessness.
D. Faintness, pallor.
C. Apprehension and restlessness.
Apprehension and restlessness are often the earliest signs of poor oxygenation and tissue perfusion. These symptoms indicate that the brain is receiving insufficient oxygen, leading to neurological distress. If left untreated, this can progress to cyanosis, altered mental status, and even respiratory failure. After a thyroidectomy, swelling, hematoma formation, or laryngeal nerve damage can compromise airway patency, making early recognition and intervention crucial to preventing life-threatening complications.
The nurse enters the room of a client and, without the use of the stethoscope, can hear the client wheezing. How should the nurse document this finding in the medical record?
A. Wheezes noted upon inspection
B. Wheezes noted upon percussion
C. Wheezes noted upon direct auscultation
D. Wheezes noted upon indirect auscultation
C. Wheezes noted upon direct auscultation
Which of the following drugs is administered to minimize respiratory secretions preoperatively?
A. Diazepam
B. Hydroxyzine
C. Atropine
D. Meperidine
C. Atropine
A nurse is assessing a patient with respiratory problem. Which clinical manifestation are most reflective of an early response to hypoxia? SATA
a. dysrhythmias
b. restlessness
c. irritability
d. cyanosis
e. apnea
f. Tachycardia
b,c,f
A nurse admits a 72-year-old patient with a medical history of hypertension, heart failure, renal failure, and depression to a general medical patient care unit. The nurse reviews the patient's medication orders and notes that the patient has three health care providers who have ordered a total of 13 medications. What is the most appropriate action for the nurse to take next?
A. Give the medications after identifying the patient using two patient identifiers
B. Provide medication education to the patient to help with adherence to the medical plan
C. Review the list of medications with the health care providers to ensure that the patient needs all 13 medications
D. Set up a medication schedule for the patient that is least disruptive to the expected treatment schedule in the hospital
C. Review the list of medications with the health care providers to ensure that the patient needs all 13 medications
A nurse who is giving a statin(Lipitor) realizes the importance of monitoring for which serious adverse reaction?
a. Pharyngitis
b. Rash/pruritus
c. Rhabdomyolysis
d. Agranulocytosis
c. Rhabdomyolysis
Which client should the nurse assess first?
A. A client with BP 150/88 mmHg reporting a headache
B. A client with RR 30 breaths/min using accessory muscles
C. A client with temperature 100.4°F (38°C)
D. A client with pulse 104 bpm after walking
B. A client with RR 30 breaths/min using accessory muscles
The patient has presented to the ambulatory surgery center to have a colonoscopy. The patient is scheduled to receive moderate sedation (conscious sedation) during the procedure. How will the nurse interpret this information?
a. The procedure results in loss of sensation in an area of the body.
b. The procedure requires a depressed level of consciousness.
c. The procedure will be performed on an outpatient basis.
d. The procedure necessitates the patient to be immobile.
b. The procedure requires a depressed level of consciousness.
Moderate sedation (conscious sedation) is used routinely for procedures that do not require complete anesthesia but rather a depressed level of consciousness. Not all patients who are treated on an outpatient basis receive moderate sedation.
A nurse is teaching a patient how to use an incentive spirometer. Place the steps of the use of an incentive spirometer in the order in which they should be informed
1. inhale slowly
2. Hold the incentive spirometer level
3. Remove the mouthpiece and exhale normally
4. keep the visual indicator at the inspiratory goal for several seconds
5. maintain a firm seal with the lips around the mouthpiece during inhalation
2,5,1,4,3
Which medication order would require follow-up by the nurse? Select all that apply.
A. Lisinopril 40 mg per os daily
B. Hydromorphone 2 mg prn
C. Ciprofloxacin 250 mg PO Q12hr x 4 days
D. Furosemide 40 mg IV QOD
E. Potassium chloride 20 mEq PO daily a.m.
correct answer A,B,D
A. Lisinopril 40 mg per os daily
Os can be mistaken as left eye. Use "PO" "by mouth" or "orally
B. Hydromorphone 2 mg prn
The order is missing the route, frequency and prn indications
C. Ciprofloxacin 250 mg PO Q12hr x 4 days
This order includes the drug, dosage, frequency, and route
D. Furosemide 40 mg IV QOD
QOD can be mistaken as QD or QID. Use "every other day"
E. Potassium chloride 20 mEq PO daily a.m
This order includes the drug, dosage, frequency and route
A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity?
A. 3+ achilles reflex
B. Faint pedal pulses
C. Feet warm to touch bilaterally
D. Capillary refill of <2 sec
B. Faint pedal pulses
This can indicate poor circulation and tissue perfusion, which puts the client at risk of impaired skin integrity
A client receiving opioid pain medication has the following vital signs:
RR 10/min
SpO₂ 92%
BP 118/72 mmHg
HR 74 bpm
Which action should the nurse take first?
A. Apply oxygen via nasal cannula
B. Stimulate the client and assess level of consciousness
C. Notify the healthcare provider
D. Administer naloxone
B – RR 10 is dangerous; stimulate and assess before meds
The nurse is caring for a postoperative client with an oxygen saturation of 90% who has decreased breath sounds in both lung bases. Which action should the nurse take?
A. Use an Incentive spirometer
B. Administer bronchodilators
C. Provide Oxygen at 2L/ min via nasal cannula
D. Elevate the head of the bed
A. Use an incentive spirometer (Correct)
an IS can increase oxygen saturation levels and promote lung expansions in post op clints
B. Administer bronchodilators
C. Provide oxygen at 2L/ min via nasal cannula
this may increase the oxygen levels in the client however it will not help with the diminished breath sounds noted in both bases
D. Elevate the head of the bed
While elevating the head of the bed can facilitate better gas exchange it will not improve diminished breath sounds
A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first?
A. a client who has heart failure and is receiving 100% oxygen via partial rebreather mask
B. a client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula
C. a client who had an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar
D. a client who has COPD and is receiving oxygen at 2 L/min via nasal canula
Correct answer A
the nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe exhaled carbon dioxide instead of receiving prescribed oxygen dose. Therefore, the nurse should first see the client who has heart failure and is receiving 100% oxygen via partial rebreather mask, oxygen is a gas that can cause toxicity and is highly combustible and higher concentration of oxygen increase the risk of client injury.
A nurse is assessing a patient to determine if it is appropriate to administer a prescribed medication via the oral route. which information indicates the nurse should ask the primary healthcare provider for a change in route? SATA
A. Nausea
B. Unconsciousness
C. Gastric suctioning
D. Emergency situation
E. Difficulty swallowing
B. Unconsciousness
D. Emergency situation
A nurse is caring for a patient admitted with heart failure who has a pulse of 130/min (irregular), BP of 80/60 mmHg, and an oxygen saturation of 91% on room air. Which of the following assessment findings would be most consistent with these vital signs?
A.Pitting edema in the lower extremitiesNot quiteWhile edema is common in heart failure, the immediate concern reflected by these specific vital signs is poor systemic perfusion and low cardiac output, best indicated by pulse quality.
B.Weak, thready radial pulseRight answerThe combination of tachycardia and hypotension suggests a low cardiac output, which would manifest as a weak and thready peripheral pulse due to poor perfusion.
C.Bounding peripheral pulses
D.Warm, pink extremities with brisk capillary refill
B.Weak, thready radial pulse
The combination of tachycardia and hypotension suggests a low cardiac output, which would manifest as a weak and thready peripheral pulse due to poor perfusion.
Four clients have the following vital signs. Which client should the nurse assess first?
A. SpO₂ 91% in a client with COPD
B. RR 32/min with nasal flaring
C. BP 90/60 mmHg after antihypertensive medication
D. Temperature 101.2°F (38.4°C) postop day 2
B – Airway/breathing always first (RR 32 + nasal flaring)
The nurse is encouraging a reluctant postoperative patient to deep breathe and cough. Which explanation can the nurse provide that may encourage the patient to comply?
a. "If you don't deep breathe and cough, you will get pneumonia."
b. "You will need to cough only a few times during this shift."
c. "Let's try clearing the throat because that will work just as well."
d. "Deep breathing and coughing will clear out the anesthesia."
ANS: D
Deep breathing and coughing expel retained anesthetic gases and facilitate a patient's return to consciousness. Although it is correct that a patient may experience atelectasis and pneumonia if deep breathing and coughing are not performed, the way this is worded sounds threatening and could be communicated in a more therapeutic manner. Deep breathing and coughing are encouraged every 2 hours while the patient is awake. Just clearing the throat does not remove mucus from deeper airways