Edited Readiness - notes that the client's tracheostomy cuff is in...

Edited Readiness The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take?

• Leave the cuff inflated and suction through the tracheostomy.
• Deflate the cuff and suction through the tracheostomy tube.
• Inflate the cuff pressure to 40 mm Hg before suctioning.
• Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning.

A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse is the MOST appropriate?

• Assess pupil size and reactivity.
• Assess oxygen saturation levels.
• Palpate dorsalis pedis pulses.
• Ask the client if he knows today's date.

The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette).Which question is MOST important for the nurse to ask?

• "Have you tried other methods to stop smoking?"
• "How long have you been smoking?"
• "Have you ever had chest pain?"
• "Do you have a partial dental bridge?"

The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour.Which is the MOST appropriate action for the nurse to take?

• Assess the patency of the PCA IV tubing.
• Determine the client's understanding of the PCA pump function.
• Obtain an order to begin a PCA infusion of fentanyl.
• Ask the client to describe the pain.

A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is MOST appropriate?

• Place the client flat on her back.
• Elevate the head of the bed 30 degrees.
• Place the client on her left side with her legs flexed.
• Place the client supine with the foot of the bed elevated.

A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status?

• Urinary output of 1,500 mL in 24 hours.
• Serum hematocrit 52%.
• Oral fluid intake of 900 mL in 24 hours.
• Blood pressure of 100/82.

The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the morning.Which medication should the nurse question giving to the client?

• 20 mg oral escitalopram (Celexa) in the morning.
• 40 mg oral furosemide (Lasix) in the morning.
• 300 mg of oral gabapentin (Neurontin) twice daily.
• 10 mg zolpidem (Ambien) at bedtime.

The home care nurse visits a client with a halo fixator traction device. Which client statement MOST concerns the nurse?

• "My wife looks at the pin sites every day."
• "I like to bathe in the tub."
• "I drove to the library yesterday."
• "I drink with a straw."

The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement?

• "I have been sleeping 6 hours at night."
• "I have lost 2 lbs in the past week."
• "Lately, I have trouble watching television."
• "I have much less muscle tension now."

The nurse on the maternity unit must accept a transfer client from a medical/surgical unit. The nurse considers which transfer client appropriate?

• A 38-year-old client with a diagnosis of systemic lupus erythematosus.
• A 45-year-old client receiving daily external radiation therapy treatments for breast cancer.
• A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg.

The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is MOST important for the nurse to make which of these statements?

• "Your parents are going to leave a half hour before the surgery."
• "You're going to talk with some other children who had this surgery."
• "If you have this surgery, your parents will buy you a new toy."
• "Take this doll and show me where the operation will be done."

The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused and incontinent of urine. What is the MOST important action for the nurse to take?

• Insert an indwelling urinary drainage catheter.
• Perform intermittent catheterization every 4 hours.
• Offer the bedpan to the client every 2 hours.
• Assist the client to a bedside commode every 2 hours.

The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned to the surgical acute-care unit after a right below-knee amputation. The client's capillary blood glucose is 480 mg/dL. The postoperative orders indicate 6 units of regular insulin subcutaneously should be administered. Which of the following is the FIRST action the nurse should take?

• Check the client records to see if insulin was given prior to surgery.
• Administer the 6 units of regular insulin subcutaneously.
• Administer the insulin when oral fluids are tolerated.
• Contact the healthcare provider.

During the admission interview, the client reports a red, itchy raised rash on the chest and lip swelling after use of aspirin and penicillin. The admission orders include bed rest, soft diet as tolerated, naproxen (Naprosyn), and cefaclor (Ceclor). Which is the BEST description of expected breath sounds heard during auscultation?

• Administer the Ceclor as ordered; do not administer the naproxen.
• Administer the naproxen as ordered; do not administer the Ceclor.
• Administer both the Ceclor and naproxen as ordered; document the client's response.
• Do not administer the Ceclor or naproxen; notify the healthcare provider.

The nurse teaches a client about how to care for an ileostomy. Which comment, if made by the client to the nurse, indicates further teaching is needed?

• "The skin around the stoma should be cleaned with warm water and thoroughly dried."
• "The appliance should fit snugly around the ileostomy opening."
• "I should take polyethylene glycol (MiraLax) with a large glass of water."
• "I will continue to take a daily multi-vitamin."

The nurse cares for a client diagnosed with chronic bronchitis and peripheral vascular disease. The nurse expects to assess which of these breath sounds?

• Continuous, high-pitched musical sounds heard on expiration.
• Soft, high-pitched interrupted sounds heard on inspiration.
• Deep, low-pitched rumbling sounds are heard mainly on expiration.
• Harsh, grating sounds heard best during inspiration.

The nurse prepares to administer gentamicin (Garamycin) to the 65-year-old client. Which is the MOST important action for the nurse to take prior to administration of the medication?

• Request a daily hemoglobin and hematocrit test.
• Monitor the serum BUN and creatinine.
• Request a highly-sensitive C-reactive protein (hs-CRP) test.
• Monitor the erythrocyte sedimentation rate (ESR).

The nurse cares for the client in the labor unit. During the transitional phase of labor, the umbilical cord becomes prolapsed. It is MOST important for the nurse to take which action?

• Place the client on her back with thighs flexed on her abdomen.
• Place the client on her left side with legs flexed.
• Place the client supine with the head of the bed elevated 30°.
• Place the client supine with the foot of the bed elevated.

The nurse cares for the client diagnosed with lung cancer. The family states that the client has become confused and that urinary output has decreased during the previous 24 hours. Which finding MOST concerns the nurse?

• 2+ pitting pretibial edema.
• Sodium 128 mEq/L.
• Weight gain of 2 kg in 24 hours.
• Urine specific gravity 1.008.

The home care nurse cares for a client who is diagnosed with hypertension and mild depression. The client's daughter states that her mother has been falling frequently. WWhich response by the nurse is BEST?

• "Let's get your mother a walker."
• "Do you think it's time to put your mother in a nursing home?"
• "When does your mother fall?"
• "Does your mother seem to be more confused lately?"

A femoral angiogram is scheduled for a client. It is MOST important for the nurse to take which action prior to the angiogram?

• Clean and shave the catheter insertion-site area.
• Locate and note the presence of peripheral pulses.
• Encourage the client to increase oral fluid intake.
• Teach coughing and deep-breathing exercises.

A child sustains a crushing chest injury in a car accident. In the emergency room, an endotracheal tube is inserted. Several hours later the nurse enters the client's room and finds the child in respiratory distress. It is MOST important for the nurse to take which action prior to the angiogram?

• Observe the color of the client's fingernail beds.
• Assess the client's blood pressure in both arms.
• Listen to the client's breath sounds.
• Assess for intercostal retractions.

The nurse cares for an elderly man diagnosed with Alzheimer's disease. It is MOST important for the nurse to take which action?

• Leave the television on all day in the client's room.
• Frequently inform the client of the room and bathroom location.
• Provide the client with newspapers and magazines.
• Assign a staff member to check on the client every 15 minutes.

The nurse is responsible for triage of injured residents of an apartment building that collapsed during a tornado. Which client should the emergency personnel see FIRST?

• A 38-year-old client with potential fracture left femur. Blood pressure 110/78, pulse 92/minute,

shallow respirations at 16/minute.

• A 42-year-old client with ecchymotic areas on the left anterior and posterior chest. Blood pressure

142/90, pulse 88/minute, shallow respirations at 20/minute.

• A 48-year-old client with severe head trauma. Blood pressure 168/52, pulse 58 per minute, irregular

respirations at 12/minute.

• A 64-year-old client complaining of left hand and wrist pain asking, "Where am I?" Blood pressure

128/72, pulse 88/minute, respirations unlabored at 16/minute.The nurse cares for a client diagnosed with Crohn's disease. The nurse instructs the client about diet.Which menu selection indicates to the nurse that teaching is effective?

• Cheeseburger on a whole-wheat bun, french fries, and an apple.
• Tomato soup, saltines, and a slice of unfrosted angel food cake.
• Baked cod, biscuit without butter, fruit roll-up.
• Macaroni and cheese, coleslaw, 2 macaroon cookies.a

The nursing team consists of one RN, one LPN/LVN and two nursing assistive personnel (NAPs). Which assignment is MOST appropriate for the LPN/LVN?

• A 38-year-old client diagnosed with Guillain-Barré syndrome receiving plasmapheresis therapy.
• A 72-year-old client admitted yesterday with a 10-day history of oral antibiotic therapy and a 24-

hour history of watery diarrhea.

• A 78-year-old client diagnosed with a thrombotic cerebrovascular accident 5 days ago.
• A 86-year-old client just admitted with malaise, a productive cough, and WBC 17,000 mm3.

The nurse cares for a client during a 24-hour urine specimen collection. Several hours later, the client tells the nurse that she has started to menstruate. Which action by the nurse is MOST appropriate?

• Inform the health care provider that the client is menstruating.
• Send the urine collected prior to the onset of the client's menstruation to the lab.
• Insert an indwelling bladder catheter during the remainder of the collection period.
• Request a separate urine collection container from the laboratory to be used during the remainder

of the urine collection period.The nurse cares for the client in the recovery room after a knee surgery procedure. The client has an oral airway in place. Which is the BEST indicator that the oral airway can be removed?

• The client has a forceful cough during re-positioning.
• The client responds to to a normal spoken voice.
• The client tries to chew on the oral airway.
• The client is able to swallow.

The nurse cares for clients in the antepartum clinic. Which client should the nurse see FIRST?

• An 18-year-old multigravida client at 28 weeks gestation with a positive indirect Coombs' test.
• A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema.
• A 30-year-old client at 26 weeks gestation with bilateral yellow breast exudate.
• A 43-year-old primigravida client at 18 weeks of gestation reporting an absence of fetal movement.

The nurse instructs a client about include digoxin (Lanoxin), furosemide (Lasix), spironolactone (Aldactone), and a low-sodium diet. Which statement by the client indicates the need for further instruction?

• "I should weigh myself every morning and call the health care provider if I gain more than a couple

of pounds in a few days."

• "I should call the health care provider immediately if I start to feel nauseated or have difficulty

breathing with normal activities."

• "I plan to use salt substitutes now that I have to limit my sodium intake."
• "I should read food and nonprescription medication labels to check the ingredients."