NP3

B. Bend the knees

To further stabilize Mr. Tan during the evisceration mentioned above, how should the nurse instruct the client to position his legs?

A. Keep the legs straight and extended

B. Bend the knees

C. Cross the legs at the ankles

D. Elevate the legs above the level of the heart

B. Ensure the reservoir bag remains inflated at all times

Mr. Ramon develops acute hypoxemia and is transitioned to a non-rebreather (NRB) mask at 12 L/min. What is a critical safety step when using this device?

A. Maintain a flow rate of 2 L/min to prevent CO2 buildup

B. Ensure the reservoir bag remains inflated at all times

C. Remove both one-way valves to allow the client to breathe room air

D. Tape the mask tightly to the client’s face with no gaps

C. Between 48 to 72 hours

After the TST has been administered, the nurse must instruct Mr. Leo on when to return for the interpretation of the test. What is the standard timeframe for reading a Mantoux test?

A. Within 12 to 24 hours

B. Between 24 to 36 hours

C. Between 48 to 72 hours

D. Exactly 7 days after injection

C. Presence of a prominent U wave

The nurse reviews the client’s Electrocardiogram (ECG). Which finding should the nurse identify as a classic indicator of the current electrolyte imbalance?
hypokalemia

A. Tall, peaked T waves - hyperkalemia

B. Widened QRS complexes

C. Presence of a prominent U wave

D. Shortened QT interval

B. The kidneys fail to convert Vitamin D to its active form

The nurse recognizes that clients with chronic kidney disease (CKD) are at high risk for hypocalcemia primarily because:

A. The kidneys excrete excessive amounts of calcium in the urine

B. The kidneys fail to convert Vitamin D to its active form

C. CKD causes the parathyroid gland to stop secreting hormones

D. The kidneys produce too much phosphorus-binding medication

During preparation for a laparoscopic procedure, the nurse understands which gas is most commonly used to inflate the client’s abdomen to create a pneumoperitoneum?

A. Oxygen

 

B. Nitrogen

C. Carbon dioxide

D. Helium

The nurse is assigned to care for an infant on the first postoperative day after a surgical repair of a cleft lip. Which nursing intervention is appropriate when caring for this child’s surgical incision?

A. Rinsing the incision with sterile water after feeding

B. Cleaning the incision only when serous exudate forms

C. Rubbing the incision gently with a sterile cotton-tipped swab

 

D. Replacing the Logan bar carefully after cleaning the incision

The nurse inserts an indwelling urinary catheter into the distended bladder of a postoperative client who has not voided for 8 hours. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client?

A. Check the specific gravity of the urine.

 

B. Clamp the tubing for 30 minutes and then release.

C. Provide suprapubic pressure to maintain a steady flow of urine.

D. Raise the collection bag high enough to slow the rate of drainage.

A client who underwent surgical repair of an abdominal aortic aneurysm is 1 day postoperative. The nurse performs an abdominal assessment and notes the absence of bowel sounds. What action would the nurse take?

A. Start client on sips of water.

B. Remove the nasogastric (NG) tube.

C. Call the surgeon immediately.

 

D. Document the finding and continue to assess for bowel sounds.

A client, who was diagnosed with a malignant tumor in the left lung, is scheduled for pneumonectomy and tells the nurse that a friend had lung surgery that required chest tubes. The client asks how long to expect chest tubes to be in place. Which statement by the nurse appropriately educates the client about the presence of a chest tube postpneumonectomy?

A. “They are generally removed after 36 to 48 hours.”

B. “Not every lung surgery requires chest tubes to be used.”

C. “They usually remain in place for a full week after surgery.”

 

D. “Your type of surgery rarely requires chest tubes to be inserted after surgery.”

A client is admitted to the cardiac intensive care unit after coronary artery bypass graft (CABG) surgery. The nurs notes that in the first hour after admission, the mediastinal chest tube drainage was 75 mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets this data and implements which intervention?

A. Identifies that the tube is draining normally

B. Assesses the tube to locate a possible occlusion

C. Auscultates the lungs for appropriate bilateral expansion

 

D. Assists client with frequent coughing and deep breathing

A postoperative client begins to drain small amounts of bright red blood from the tracheostomy tube 24 hours after a laryngectomy. Which priority action would the nurse implement?

A. Notify the surgeon.

B. Increase the frequency of suctioning.

C. Add moisture to the oxygen delivery system.

D. Document the character and amount of drainage.

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

A. Urinary output of 20 mL/hr

B. Temperature of 37.6° C (99.6° F)

C. Blood pressure of 100/70 mm Hg

D. Serous drainage on the surgical dressing

The nurse is going to suction an adult client with a tracheostomy who has respiratory secretions. Which intervention would the nurse implement to perform this procedure safely?

A. Occluding the Y-port of the suction catheter while advancing it

 

B. Applying continuous suction in the airway for up to 20 seconds

C. Setting the suction pressure range between 160 and 180 mm Hg

D. Hyperoxygenating the client by asking the client to take four to five deep breaths

The nurse is giving a client with chronic obstructive pulmonary disease (COPD) information related to the positions used to breathe more easily. The nurse teaches the client to assume which position?

A. Sit bolt upright in bed with the arms crossed over the chest.

B. Lie on the side with the head of the bed at a 45-degree angle.

 

C. Sit in a reclining chair tilted slightly back with the feet elevated.

D. Sit on the edge of the bed with the arms leaning on an overbed table.

The nurse caring for an infant demonstrating diarrhea would monitor the infant for which early sign of dehydration?

A. Cool extremities

B. Gray, mottled skin

C. Capillary refill of 3 seconds

 

D. Apical pulse rate of 200 beats/min

The nurse has provided home care instructions to a client with prostate cancer who has been hospitalized for a transurethral resection of the prostate (TURP). Which statement by the client indicates the need for further teaching?

A. “Prune juice needs to be included in my diet.”

 

B. “I need to avoid strenuous activity for 4 to 6 weeks.”

C. “My intake of water needs to be at least six to eight glasses daily.”

D. “I can’t lift or push objects that weigh more than 30 pounds.”