MERGED KAPLAN EXIT EXAM 1 and 2 LATEST UPDATE 2022 (New!!!)
1) The nurse caresfor a client with a cuffed tracheostomy tube.Before performing oral care,
... [Show More] the nurse notesthat the client's tracheostomy c
1. Leave the cuffinflated and suction through the tracheostomy.
2. Deflate the cuff and suction through the tracheostomy tube.
3. Inflate the cuff pressure to 40 mm Hg before suctioning.
4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning.
1) CORRECT - Implementation: outcome desired; cuffinflation decreasesthe risk of aspiration; cuff position and pressure should be assessed f
2) Implementation: outcome not desired; accumulated oral secretions above the cuff will drain into the bronchi; increased risk of infection
3) Implementation: outcome not desired; cuff pressure should be lessthan 20 mm Hg (25 cm H2O); risk of trauma to trachea with higher pressure
4) Implementation: outcome not desired; increases the risk oftrauma to lower airways
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2) A young adult brings a friend to the emergency department and statesthat the friend has been using heroin. Which action by the nurse isth
1. Assess pupil size and reactivity.
2. Assess oxygen saturation levels.
3. Palpate dorsalis pedis pulses.
4. Ask the client if he knows today's date.
1) Assessment: outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin overdose
2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas exchange and possible respiratory arrest
3) Assessment: outcome not priority; most important to assess airway and breathing
4) Assessment: outcome not priority butmay be appropriate; drowsiness and euphoria may be seen; not priority
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3) The client tellsthe clinic nurse that the client isthinking about using nicotine polacrilex (Nicorette). Which question is MOST important
1. "Have you tried other methodsto stop smoking?"
2. "How long have you been smoking?"
3. "Have you ever had chest pain?"
4. "Do you have a partial dental bridge?"
1) Assessment: outcome not priority but may be appropriate; can be asked as part of assessment
2) Assessment: outcome not priority butmay be appropriate; should be assessed for further teaching
3) CORRECT- Assessment: outcome priority; action of nicotine is vasoconstriction; increases heart rate and myocardial oxygen consumption; inc
4) Assessment: outcome may be appropriate but not priority; gum is place between cheek and gums; may stain dental work
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4) The nurse cares forthe client with a client controlled analgesia (PCA) pump. The nurse determinesthat the client has pressed the button 1
1. Assessthe patency of the PCA IV tubing.
2. Determine the client's understanding ofthe PCA pump function.
3. Obtain an order to begin a PCA infusion of fentanyl.
4. Ask the client to describe the pain.
1) Assessment: outcome not priority butmay be appropriate; if tubing is obstructed, alarm is activated
2) Assessment: outcome may be appropriate but not priority; more important to determine pain level, description ofthe pain, region and radiat
3) Implementation: outcome not desired; more important to assessseverity of pain and pain relief first
4) CORRECT - Assessment: outcome priority; must validate that client isin pain before implementation
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5) A pregnant woman receives an epidural anesthetic. After administration ofthe epidural anesthetic, the client's blood pressure changes from1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on herleft side with her legs flexed.
4. Place the client supine with the foot ofthe bed elevated.
1) Implementation: outcome not desired; no increase in venous return
2) Implementation: outcome not desired; will decrease venousreturn
3) CORRECT -Implementation: outcome desired; will increase venousreturn and cardiac output; fetal pressure on inferior vena cava reduced
4) Implementation: outcome not desired; elevation oflegs will increase venousreturn, but fetal pressure on vena cava will prevent blood retu
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6) A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid s
1. Urinary output of 1,500 mL in 24 hours.
2. Serum hematocrit 52%.
3. Oral fluid intake of 900 mL in 24 hours.
4. Blood pressure of 100/82. [Show Less]