A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply)
a. Restlessness
b. Tachypnea
c. Bradycardia
d...
NUR 380 Proctored Exam 3 2024
A nurse is assessing a client who has an acute respiratory infection, increasing the risk for
hypoxemia. Which of the following findings are early indications that should alert the nurse that
the client is developing hypoxia? (Select all that apply)
a. Restlessness
b. Tachypnea
c. Bradycardia
d. Confusion
e. Hypertension - a, b, d, e
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 nausea or difficulty breathing
e. Post "no smoking" signs in prominent locations - c, d, e
A nurse is caring for a client who is having difficulty breathing. The client is lying in 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 to Fowler's position
c. Promote removal of pulmonary secretions
d. Obtain a specimen for arterial blood gases - b
A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow
which of the following guidelines? (Select all that apply)
a. Apply suction while withdrawing the catheter
b. Perform suctioning on a routine basis every 2-3 hours
c. Maintain medical adepts during suctioning
d. Use a new catheter for each suctioning attempt
e. Apply suction for 10-15 seconds - a, d, e
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 cannula surfaces in a circular motion from the stoma site outward
d. Replace the tracheostomy ties with new ties
e. Cut a slit in gauze squares to place beneath the tube holder - a, b, c
, A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available
is methylprednisolone injection 40mg/mL. How many mL should the nurse administer? (Round
answer to the nearest tenth. Do not use a trailing zero.) - 0.3 mL IV bolus
A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 min. The nurse
should set the IV infusion pump to deliver how many mL/hr? (round answer to the nearest whole
number. Do not use a trailing zero.) - 400 ml/hr IV
A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over
30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the
manual IV infusion to deliver how many gtt/min? (Round answer to the nearest whole number.
Do not use a trailing zero.) - 83 gtt/min IV
A nurse is preparing to administer metoprolol 200 mg PO daily. The amount available is
metoprolol 100 mg/tablet. How many tablets should the nurse administer? (Round the answer to
the nearest whole number. Do not use a trailing zero.) - 2 tablets daily
A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-aged child
who weighs 66 lb. The amount available is ketorolac injection 30mg/mL. How many mL should
the nurse administer per dose? (Round the answer to the nearest whole number. Do not use a
trailing zero.) - 0.5 mL IV
A nurse is preparing to administer dextrose 5% in water (DsW) 1,000 mL IV to infuse over 10
hr. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to
the nearest whole number. Do not use a trailing zero.) - 100 mL/hr IV
A nurse is preparing to administer acetaminophen 320 mg PO every 4 hr PRN for pain. The
amount available is acetaminophen liquid 160mg/5mL. How many mL should the nurse
administer per dose? (Round answer to the nearest tenth. Use a leading zero if it applies. Do not
use a trailing zero.) - 10 mL PO
A nurse is preparing to administer dextrose 5% in lactated Ringer's (DsLR) 1,000 mL to infuse
over 6 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should adjust the
manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole
number. Do not use a trailing zero.) - 42 gtt/min IV
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place,
and time and can follow directions. Which of the following actions should the nurse take to
decrease the risk of another fall? (select all that apply)
a. Place a belt restraint on the client when they are sitting on the bedside commode
b. Keep the bed in its lowest position with all side rails up
c. Make sure the client's call light is within reach
d. Provide the client with nonskid footwear
e. Complete a fall-risk assessment - c, d, e
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