Exam One - Practice Q's Flashcards
A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse
take first?
A. Encourage the client to increase fluid intake.
B. Assess the clients level of consciousness.
C. Raise the head of the bed to at least 45 degrees.
D. Provide the client with humidified oxygen.
B. Assess the clients level of consciousness
A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires
immediate action?
A. Increase temperature
B. Absent breath sounds
C. Productive cough
D. Incisional discomfort
B. Absent breath sounds
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?
A. Measure oxygen saturation before and after a 12-minute walk.
B. Verify that the client understands all possible complications
C. Explain the procedure in detail to the client and the family.
D. Validate that informed consent has been given by the client.
D. Validate that informed consent has been given by the client
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
A. The client rates pain as a 5/10 at the site of the procedure.
B. A small amount of drainage from the site is noted.
C. Pulse oximetry is 93% on 2 liters of oxygen.
D. The trachea is deviated toward the opposite side of the neck.
D. The trachea is deviated toward the opposite side of the neck
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a
flight of stairs. Which intervention should the nurse include in this clients plan of care?
A. Assistance with activities of daily living
B. Physical therapy activities every day
C. Oxygen therapy at 2 liters per nasal cannula
D. Complete bedrest with frequent repositioning
A. Assistance with activities of daily living
A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the
nurse include in this clients plan of care? (Select all that apply.)
A. Encourage deep breathing and coughing
B. Implement an air mattress overlay
C. Ambulate the client three times each day
D. Provide a diet high in protein and vitamins
E. Administer acetaminophen (Tylenol) twice daily.
A. Encourage deep breathing and coughing
C. Ambulate the client three times each day
D. Provide a diet high in protein and vitamins
A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing
what percentage of oxygen in the room air?
a. 14%
b. 21%
c. 28%
d. 31%
B. 21%
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
A. Administer prescribed anxiolytic medication
B. Ensure informed consent is on the chart
C. Reinforce any teaching done previously
D. Start the preoperative antibiotic infusion.
B. Ensure informed consent is on the chart
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and
the eyelids are swollen. What action by the nurse takes priority?
A. Assess the clients oxygen saturation
B. Notify the Rapid Response Team
C. Oxygenate the client with a bag-valve-mask
D. Palpate the skin of the upper chest.
A. Assess the clients oxygen saturation
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?
A. Elevate the head of the clients bed
B. Measure and compare cuff pressures.
C. Place the client on NPO status
D. Request that the client have a swallow study.
B. Measure and compare cuff pressures
An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the
UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?
a. Assess the clients lung sounds.
B. Assign a different UAP to the client.
C. Report the UAP to the manager.
D. Request thicker liquids for meals.
A. Assess the clients lung sounds
A student nurse is providing tracheostomy care. What action by the student requires intervention by the
instructor?
A. Holding the device securely when changing ties
B. Suctioning the client first if secretions are present
C. Tying a square knot at the back of the neck
D. Using half-strength peroxide for cleansing
C. Tying a square not at the back of the neck
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student
demonstrates that more teaching is needed?
A. Applying suction while inserting the catheter
B. Preoxygenating the client prior to suctioning
C. Suctioning for a total of three times if needed
D. Suctioning for only 10 to 15 seconds each time
A. Applying suction while inserting the catheter
A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that
goals for a priority diagnosis are being met?
A. 100% of meals being eaten by the client
B. Intact skin behind the ears
C. The client understanding the need for oxygen
D. Unchanged weight for the past 3 days
B. Intact skin behind the ears
Oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosis of Risk for Impaired Skin Integrity
A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing
with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the
nurse is most appropriate?
A. Call the operating room to inform them of a pending emergency case.
B. No action is needed at this time; this is a normal finding in some clients.
C. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
D. Stay with the client and have someone else call the provider immediately.
D. Stay with the client and have someone else call the provider immediately
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best
indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
A. The client demonstrates good understanding of stoma care.
B. The client has joined a book club that meets at the library.
C. Family members take turns assisting with stoma care.
D. Skin around the stoma is intact without signs of infection.
B. The client has joined a book club that meets at the library
A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?
A. Apply water-soluble ointment to nares and lips.
B. Periodically turn the oxygen down or off.
C. Remove the tubing from the clients nose.
D. Turn the client every 2 hours or as needed.
A. Apply water-soluble ointment to nares and lips
A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.)
A. The client does not allow smoking in the house.
B. Electrical cords are in good working order.
C. Flammable liquids are stored in the garage.
D. Household light bulbs are the fluorescent type.
E. The client does not have pets inside the home.
A. The client does not allow smoking in the house.
B. Electrical cords are in good working order.
C. Flammable liquids are stored in the garage.
A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to
unlicensed assistive personnel (UAP)? (Select all that apply.)
A. Applying water-soluble lip balm to the clients lips
B. Ensuring the humidification provided is adequate
C. Performing oral care with alcohol-based mouthwash
D. Reminding the client to cough and deep breathe often
E. Suctioning excess secretions through the tracheostomy
A. Applying water-soluble lip balm to the clients lips
D. Reminding the client to cough and deep breathe often
A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse
offer to help the client maintain self-esteem? (Select all that apply.)
A. Create a communication system.
B. Dont go out in public alone.
C. Find hobbies to enjoy at home.
D. Try loose-fitting shirts with collars.
E. Wear fashionable scarves.
A. Create a communication system.
D. Try loose-fitting shirts with collars.
E. Wear fashionable scarves.
A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.)
a. Cognition
b. Dexterity
c. Hydration
d. Range of motion
e. Vision
a. Cognition
b. Dexterity
d. Range of motion
e. Vision
While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?
a. Contact the provider and prepare for intubation.
b. Administer prescribed albuterol nebulizer therapy.
c. Place the client in high-Fowlers position.
d. Ask the client to perform deep-breathing exercises.
a. Contact the provider and prepare for intubation.
After teaching a client how to perform diaphragmatic breathing, the nurse assesses the clients understanding. Which action demonstrates that the client correctly understands the teaching?
a. The client lays on his or her side with his or her knees bent.
b. The client places his or her hands on his or her abdomen.
c. The client lays in a prone position with his or her legs straight.
d. The client places his or her hands above his or her head.
b. The client places his or her hands on his or her abdomen
While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?
a. Assess for drainage from the site.
b. Cover the insertion site with sterile gauze.
c. Contact the provider and obtain a suture kit.
d. Reinsert the tube using sterile technique.
B. Cover the insertion site with sterile gauze