A nurse is assessing a client who has an acute respiratory infection that
puts her at risk for hypoxemia. Which of the following findings are early
indications that should alert the nurse that the client is developing
hypoxemia? Select all that apply.
A. restlessness
B. tachypnea
C. bradycardia
D. confusion
E. pallor - ANS ✓A. restlessness
B. tachypnea
D. confusion
E. pallor
A provider is discharging a client who has a prescription for home oxygen
therapy via nasal cannula. Client and family teaching by the nurse should
include which of the following instructions. Select all that apply.
A. apply petroleum jelly around and inside the nares.
B. remove the nasal cannula during mealtimes.
C. check the position of the cannula frequently.
D. report any nasal stuffiness, nausea, or fatigue.
E. post "no smoking" signs in a prominent location. - ANS ✓C. check the
position of the cannula frequently.
D. report any nasal stuffiness, nausea, or fatigue.
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E. post "no smoking" signs in a prominent location.
A nurse is caring for a client who is having difficulty breathing. The client is
lying in a bed and is already receiving oxygen therapy via nasal cannula.
Which of the following interventions is the nurse's priority?
A. increase the oxygen flow.
B. assist the client into Fowler's position.
C. promote removal of pulmonary secretions.
D. obtain a specimen for arterial blood bases. - ANS ✓B. assist the client into
Fowler's position.
A nurse is preparing to perform endotracheal suctioning for a client. The
nurse should follow which of the following guidelines?
A. apply suction while withdrawing the catheter.
B. perform suctioning on a routine bases, every 2 to 3 hours.
C. maintain medical asepsis during suctioning.
D. use a new catheter for each suctioning attempt.
E. limit total suctioning time to 5 minutes. - ANS ✓A. apply suction while
withdrawing the catheter.
D. use a new catheter for each suctioning attempt.
E. limit total suctioning time to 5 minutes.
A nurse is caring for a client who has a tracheostomy. Which of the
following actions should the nurse take when providing tracheostomy
care? Select all that apply.
A. apply the oxygen source loosely if the SpO2 decreases during the
procedure.
B. use surgical asepsis to remove and clean the inner cannula.
C. clean the outer surfaces in a circular motion from the stoma site
outward.
D. replace the tracheostomy ties with new ties.
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E. cut a slit in gauze squares to place beneath the tube holder. - ANS ✓A.
apply the oxygen source loosely if the SpO2 decreases during the procedure.
B. use surgical asepsis to remove and clean the inner cannula.
C. clean the outer surfaces in a circular motion from the stoma site
outward.
A function of the venous system includes:
a. holding more blood when blood volume increases.
b. conserving fluid and plasma proteins that leak out of the capillaries.
c. forming a major part of the immune system that defense the body against
disease.
d. absorbing lipids from the intestinal tract. - ANS ✓A. Holding more blood
when blood volume increases.
Which of the following organs aid the lymphatic system?
A. liver, lymph nodes, and stomach.
B. pancreas, small intestine, and thymus
C. spleen, tonsils, and thymus
D. pancreas, spleen, and tonsils - ANS ✓C. spleen, tonsils, and thymus
Ms. T has come for a prenatal visit. She reports dependent edema,
varicosities in the legs, and hemorrhoids. What is the best response?
A. If these symptoms persist, we will perform an amniocentesis.
B. If these symptoms persist, we will discuss having you hospitalized.
C. The symptoms are caused by the pressure of the growing uterus on the
veins. They are usual conditions of pregnancy.
D. At this time, the symptoms are a minor inconvenience. You should learn
to accept them. - ANS ✓C. The symptoms are caused by the pressure of the
growing uterus on the veins. They are usual conditions of pregnancy.
A patient's pulse with an amplitude of 3+ indicates:
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a. irregular, with 3 premature beats
b. increased, full
c. normal
d. weak - ANS ✓b. increased, full
Inspection of a person's right hand reveals a red swollen area. To further
assess for infection, you would palpate the:
a. cervical node
b. axillary node
c. epitrochlear node
d. inguinal node - ANS ✓c. epitrochlear node
To screen for deep vein thrombosis, you would:
A. measure the circumference of the ankle.
B. check the temperature with the palm of the hand.
C. compress the dorsalis pedis pulse, looking for blood return.
D. measure the widest point with a tape measure. - ANS ✓D. measure the
widest point with a tape measure.
During the examination of the lower extremities, you are unable to palpate
the popliteal pulse. You should:
A. proceed with the examination. It is often impossible to palpate this pulse.
B. refer the patient to a vascular surgeon for further evaluation.
C. schedule the patient for a venogram.
D. Schedule the patient for an arteriogram. - ANS ✓A. proceed with the
examination. It is often impossible to palpate this pulse.
You assess a patient who has 4+ edema of the right leg. What is the best way
to document this finding?
A. mild pitting, no perceptible swelling of the leg.
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