1.0M8E_ N211
1.25 points possible (graded, results hidden)
Which intervention should the RN perform for a client with a chronic cough, sputum
... [Show More] production,
and dyspnea that has been worsening over time?
Restrict fluid intake to 1000 mL per day.
Position the client in a supine position.
Administer oxygen at 10 L/minute via nasal canula.
Teach the client pursed lip breathing.
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2.0M8E_N211
1.25 points possible (graded, results hidden)
Which nursing interventions should the RN implement to prevent atelectasis? Select all that
apply.
Encourage early ambulation.
Change patient position frequently.
Assist with coughing and deep breathing exercises.
Obtain order for daily chest x-ray.
Limit the use of opioids to manage pain.
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3.0M8E _N211
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Which etiology would the RN identify in the client with pneumonia who has been losing weight?
Insensible fluid loss.
Elevated body temperature.
Retained secretions.
Shortness of breath.
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4.0M8E_ N211
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The RN administers the prescribed sedation to the intubated client with acute respiratory distress
syndrome (ARDS). What is the primary rationale for this intervention?
To reduce the production of secretions.
To decrease oxygen consumption.
To prevent mechanical ventilator malfunction.
To promote lung volume expansion.
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5.0M8E_ N211
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The RN is assessing a client with pneumonia who reports chest pain during inspiration and
coughing. Which assessment data would be associated with this symptom?
Expiratory wheeze.
Absent breath sounds.
Distant heart sounds.
Pleural friction rub.
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6.0M8E_ N211
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The RN assesses a client admitted to the Emergency Department following a motor vehicle
accident. The RN notes a paradoxical chest rise, multiple bruises across the chest and torso,
crepitus, and tachypnea. Which intervention is immediately necessary?
Insertion of a chest tube.
Stabilization of the airway.
Administration of analgesics.
Application of a chest binder.
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7.0M8E_ N211
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Which client would the RN identify as being at increased risk for aspiration?
The patient with a tube feeding with the head of the bed at a 45-degree angle.
The patient with a non-functioning nasogastric tube.
The patient with an endotracheal tube with a cuff pressure of 25 cm H2O.
The patient in a side lying position following an endoscopy.
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8.0M8E_ N211
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The RN is teaching the client how to administer a metered-dose inhaler using the open-mouth
technique? Place the steps in the correct order.
1. Position the inhaler one to two inches from your mouth.
2. Shake the inhaler.
3. Rinse your mouth after using the inhaler.
4. Hold your breath for several seconds, then exhale.
5. Inhale slowly while pressing the inhaler.
5,4,3,1,2
2,5,4,3,1
2,1,5,4,3
3,2,4,5,1
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9.0M8E_ N211
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Which information should the RN provide when educating a client with chronic obstructive
pulmonary disease (COPD) who is prescribed two metered-dose inhalers?
Exhale through the device after administering the medication.
Rinse the mouth after administering each medication.
Self-administer the bronchodilator last.
Wait at least one minute between each medication.
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10.0M8E_ N211
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Which outcome is appropriate for the client with the medical diagnosis of chronic obstructive
pulmonary disease and the nursing diagnosis of Activity Intolerance?
The patient will:
Shower immediately after waking up in the morning.
Dorsiflex and plantarflex feet bilaterally before walking.
Demonstrate pursed-lip breathing.
Ambulate 100 feet without experiencing dyspnea.
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11.0M8E_ N211
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The RN observes the assistive personnel (AP) removing the nasal cannula from the client with
chronic obstructive pulmonary disease (COPD) while ambulating the client to the bathroom.
Which is the appropriate action for the RN take?
Replace oxygen on the patient and speak to the AP in private concerning the actions.
Explain to the AP in front of the client that oxygen must be left in place at all times.
Tell the client to not walk around the room without the oxygen.
Praise the AP since this prevents the client from tripping on the oxygen tubing.
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