A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient’s care? A. Perform postural drainage and chest physiotherapy every 4 hours. B. Allow the patient to decide whether she needs aerosolized medications. C. Place the patient… Read More »
Nurse Channing is caring for four clients and is preparing to do his initial rounds. Which client should the nurse assess first? A. A client with diabetes being discharged today. B. A 35-year-old male with tracheostomy and copious secretions. C. A teenager scheduled for physical therapy this morning. D. A 78-year-old female… Read More »
There are four clients with infections in the ED and only one private room is available. Which among the clients is the most appropriate to occupy the private room? A. A client with a cough who may have tuberculosis B. A client with toxic shock syndrome and a temperature of 102.4°F (39.1°C) C. A… Read More »
The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next? A. Reassure the patient that the ventilator will do the work of breathing for… Read More »
Nurse Vivian is reviewing immunizations with the caregiver of a 72-year-old client with a history of cerebrovascular disease. The caregiver learns which immunization is a priority for the client? A. Hepatitis A vaccine B. Lyme’s disease vaccine C. Hepatitis B vaccine D. Pneumococcal vaccine Correct Answer: D. Pneumococcal vaccine… Read More »
What is regarded as one of the priority actions that must be accomplished when a primary assessment of a trauma client is conveyed? A. Taking a full set of vital sign measurements. B. Completing a brief neurologic assessment. C. Monitoring pulse oximetry reading. D. Palpating and auscultating the abdomen. … Read More »
The nurse is caring for four clients receiving IV infusions of normal saline. Which client is at the highest risk for bloodstream infection? A. A client who has a non-tunneled central line in the left internal jugular vein. B. A client with an implanted port in the right subclavian vein. C. A client with… Read More »
The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient’s comfort for this problem? A. Suggest that the patient’s oxygen be humidified. B. Suggest that a… Read More »
You are admitting a patient for whom a diagnosis of pulmonary embolism must be ruled out. The patient’s history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolism? A. The patient was recently in a motor vehicle accident B. The patient participated in an aerobic exercise program… Read More »
Prior to oral defense, a 21-year-old nursing student goes straight to the clinic due to tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are also observed. What is the nursing priority action for this situation? A. Give supplemental oxygen B. Allow the student to breathe into a paper bag C.… Read More »