Road Runner Respiratory
Which nursing action is most important to ensure proper tube placement when caring for a patient with an endotracheal tube?
Auscultating the lungs for bilateral breath sounds
Monitoring blood gas values every 72 hours
Providing oral hygiene daily
Turning the patient every 2 hours from side to side
Auscultating the lungs for bilateral breath sounds
Prior to reaching the target heart rate, a patient undergoing an exercise stress test develops chest pain. Which should be the priority nursing action?
Administer analgesia and slow the test
Administer sublingual nitroglycerin to allow the patient to finish the test
Initiate cardiopulmonary resuscitation
Stop the test and monitor the patient closely
Stop the test and monitor the patient closely
A patient diagnosed with shock is receiving fluid replacement therapy. Which will the nurse monitor for? Select all that apply.
Balance
Orientation status
Strength
Urinary output
Vital signs
orientation, urinary output, vital signs
Which assessment finding(s) should concern the nurse who is caring for a patient diagnosed with type 2 diabetes? Select all that apply.
Decreased appetite
Fatigue
Halitosis
Increased energy level
Poor wound healing
Fatigue and poor wound healing
Hyperactive bowel sounds in one quadrant and absent bowel sounds in other quadrants plus nausea and vomiting may indicate:
a. pancreatitis
b. cholecystitis
c. gastrointestinal bleeding
d. intestinal obstruction
intestinal obstruction
The nurse is assessing a patient diagnosed with COPD. Which clinical manifestations will the nurse assess for? Select all that apply
Congestion
Dyspnea
Excessive energy
Increased appetite
Cough
Sputum production
Tripod positioning
dyspnea, cough, sputum production, tripod positioning
A patient with heart failure is exhibiting signs and symptoms of pulmonary edema. How should the nurse best position the patient?
Supine position
High Fowler’s position
Trendelenburg position
Left side-lying position
High Fowler's
Which assessment finding by the nurse most likely indicates that the patient is in the irreversible stage of shock?
A. Anuria
B. Blood pressure 102/52
C. Cool, clammy skin
D. Respiratory rate 10/minute
anuria
Which assessment finding by the nurse would indicate that the patient may be developing diabetic peripheral neuropathy?
Decreased capillary refill, pallor
Hypoglycemia, decreased level of consciousness
Increased thirst, polyuria
Numbness, pain in hands and feet
numbness, pain in hands and feet
The nurse hears in report that a patient is suspected of having ascites. WHich action is the nurse most likely to initiate for this specific condition?
a. Elevate the head of the bed 30-45 degrees
b. Assess for pain every 30-60 minutes
c. Perform serial measurements of abdominal girth
d. Slightly elevate legs and buttocks to help expel flatus
perform serial measurements of abdominal girth
The nurse is assessing a patient diagnosed with tuberculosis. Which assessment finding supports this diagnosis?
Cough producing clear sputum
Hemoptysis
Productive cough with white sputum
Wheezing
Hemoptysis
The nurse is assessing a patient with right-sided heart failure. Which assessment finding is most consistent with right-sided heart failure?
Distended neck veins
Dry cough
Orthopnea
Pulmonary edema
distended neck veins
Which complication should the nurse monitor for in the patient diagnosed with a calcium level of 18 mg/dL?
severe constipation
The nurse is caring for a patient diagnosed with hyperthyroidism. Which assessment finding is of concern?
Cold intolerance
Bradycardia
Tachycardia
Weight gain
tachycardia
A nurse is reviewing the laboratory data of a client who has an acute exacerbation of Crohn's disease. Which of the following lab results should the nurse expect to be elevated? Select all that apply.
A. Hematocrit
B. Erythrocyte sedimentation rate
C. WBC
D. Folic acid
E. Albumin
Sed rate and WBC
A patient presents to the emergency department with a suspected diagnosis of influenza. Which clinical manifestation(s) will the nurse assess to support this diagnosis? Select all that apply.
Cough
Fatigue
Fever
Headache
Myalgia
all of the above
A patient is recovering from mechanical valve replacement surgery for valvular disease.
Which patient teaching should be the priority for this patient?
Antibiotic therapy for four to six weeks
Anticoagulant therapy for life
Episodic use of antiarrhythmic medications
Long-term use of diuretics
anticoagulant therapy for life
Which teaching point(s) should the nurse include when educating a patient on how to manage and prevent a sickle cell crisis? Select all that apply.
A. Avoid dehydration
B. Do not eat foods containing folic acid or iron
C. Keep immunizations updated
D. Protect skin from trauma
E. Take opioids only as prescribed
avoid dehydration, keep immunizations updated, protect skin from trauma, take opioids only as prescribed
The nurse is caring for a patient diagnosed with diabetes insipidus. The nurse monitors for which therapeutic effect as a result of the administration of vasopressin?
Decreased blood pressure
Decreased serum glucose
Decreased thirst
Decreased urine output
decreased urine output
A nurse is planning care for a client who has Stage 4 chronic kidney disease. Which of the following actions should the nurse include in the plan of care? Select all that apply.
A. Assess for jugular vein distention
B. Provide frequent mouth rinses.
C. Auscultate for a pleural friction rub
D. Provide a high-sodium diet
E. Monitor for dysrhythmias
provide frequent mouth rinses
auscultate for pleural friction rub
monitor for dysrhythmias
A patient comes into the clinic complaining of hoarseness that has lasted about a month. Which diagnosis will the nurse suspect as consistent with this finding?
Chronic pharyngitis
Chronic tonsillitis
Laryngeal cancer
Laryngeal polyps
laryngeal cancer
The nurse is admitting a pre-operative female patient who takes a daily oral contraceptive.
The nurse's postoperative plan of care should include which intervention?
Cessation of the oral contraceptives until 3 weeks postoperative
Dependent positioning of the patient’s extremities when at rest
Doppler ultrasound of peripheral circulation twice daily
Early ambulation and leg exercises
early ambulation and leg exercises
A patient presents to the emergency room with a chemical burn to both hands. What is the nurse’s first intervention?
A. Contact the Poison Control Center to determine the most appropriate neutralizing
agent.
B. Delay treatment until the chemical is correctly identified.
C. Elevate the extremities to promote circulation.
D. Protect yourself, remove patient’s clothing, and begin irrigation with copious
amounts of water.
Protect yourself, remove patient’s clothing, and begin irrigation with copious
amounts of water.
The nurse is caring for a patient diagnosed with adrenal cortex hyperfunction (Cushing’s disease). Which assessment finding is of concern?
Hyperglycemia
Hyperkalemia
Weight loss
Hypotension
hyperglycemia
A nurse is planning care for a client who has prerenal acute kidney injury (AKI) following abdominal aortic aneurysm repair. Urinary output is 60 mL in the past 2 hour, and BP is 92/58 mm Hg. The nurse should expect which of the following interventions?
A. Prepare the client for a CT scan w/ contrast dye.
B. Plan to administer nitroprusside
C. Prepare to administer a fluid challenge
D. Plan to position the client in Trendelenburg
C. Plan to administer a fluid challenge