NCLEX - w15 - Oxygenation

Question 1

Which of the following are early signs of hypoxemia? (Select all that apply)

A. Confusion
B. Elevated blood pressure
C. Restlessness
D. Bradycardia

Answer 1

A and C.

Rationale:
Early signs of hypoxia include confusion and restlessness. Elevated blood pressure and bradycardia are not typically associated with early hypoxemia.

Question 2

Which of the following measures can reduce or prevent the incidence of atelectasis in a post-op client?
a. Chest physiotherapy
b. Mechanical ventilation c. Reducing oxygen requirements
d. Use of an incentive spirometer

Answer 2

d. Use of an incentive spirometer

Rationale:
Incentive spirometry encourages patients to take deep breaths, which helps to expand the lungs and prevent atelectasis. Chest physiotherapy may be used to treat atelectasis, but it is not a preventative measure. Mechanical ventilation may be necessary in some cases, but it is not the primary method of preventing atelectasis. Reducing oxygen requirements is important, but it does not directly address the issue of atelectasis.

Question 3

A nurse is caring for a client who is receiving oxygen via a nasal cannula. The client’s oxygen saturation is 88%. Which of the following actions should the nurse take first?

a. Increase the oxygen flow rate.
b. Notify the provider.
c. Reassess the client’s oxygen saturation.
d. Check the nasal cannula for kinks.

Answer 3

d. Check the nasal cannula for kinks.

Rationale:
Before taking any other action, the nurse should ensure that the oxygen delivery system is functioning properly. Kinks in the tubing can obstruct oxygen flow and lead to low oxygen saturation readings. After checking for kinks, the nurse should reassess the client’s oxygen saturation. If the saturation remains low, the nurse may need to increase the oxygen flow rate or notify the provider.

Question 4

A nurse is assessing a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect?

a. Barrel chest
b. Clubbing
c. Cyanosis
d. All of the above

Answer 4

d. All of the above

Rationale:
All of these findings are common in clients with COPD. Barrel chest occurs due to air trapping in the lungs. Clubbing is a sign of chronic hypoxia. Cyanosis is a bluish discoloration of the skin and mucous membranes, indicating inadequate oxygenation

Question 5

A nurse is teaching a client about using a peak flow meter. Which of the following instructions should the nurse include?

a. Stand up straight and take a deep breath.
b. Exhale slowly and gently into the mouthpiece.
c. Record the highest of three readings.
d. Use the peak flow meter only when you have symptoms.

Answer 5

c. Record the highest of three readings.

Rationale:
Clients should be instructed to take three peak flow readings and record the highest value. They should stand up straight and take a deep breath before forcefully exhaling into the mouthpiece. Peak flow meters should be used regularly, even when the client is not experiencing symptoms, to monitor lung function and detect early changes.

Question 6

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when suctioning the tracheostomy?

a. Insert the suction catheter as far as it will go.
b. Apply suction while inserting the catheter.
c. Use a sterile suction catheter for each suctioning attempt.
d. Hyperoxygenate the client before and after suctioning.

Answer 6

d. Hyperoxygenate the client before and after suctioning.

Rationale: Hyperoxygenating the client before and after suctioning helps to prevent hypoxia. The suction catheter should be inserted only as far as necessary to remove secretions and should not be forced. Suction should only be applied while withdrawing the catheter. While tracheal suctioning in a healthcare setting is a sterile procedure, clean technique is typically used in the home setting.

Question 7

A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse take to prevent ventilator-associated pneumonia (VAP)?

a. Elevate the head of the bed to 30-45 degrees.
b. Provide oral care every 2 hours.
c. Suction the endotracheal tube every 4 hours.
d. Change the ventilator tubing every 24 hours.

Answer 7

a. Elevate the head of the bed to 30-45 degrees.

Rationale:
Elevating the head of the bed reduces the risk of aspiration and VAP. Oral care should be provided more frequently, ideally every 2 hours or as needed. Suctioning should only be performed when clinically indicated, as excessive suctioning can increase the risk of infection. Ventilator tubing should be changed according to hospital policy, not necessarily every 24 hours.

Question 8

A nurse is caring for a client who has a chest tube. Which of the following findings should the nurse report to the provider immediately?

a. Tidling in the water-seal chamber.
b. Bubbling in the suction control chamber.
c. Continuous bubbling in the water-seal chamber. d. Drainage of 100 mL in the first hour.

Answer 8

c. Continuous bubbling in the water-seal chamber.

Rationale:
Continuous bubbling in the water-seal chamber indicates an air leak in the system, which should be reported to the provider immediately. Tidling in the water-seal chamber is a normal finding, reflecting the client’s respirations. Bubbling in the suction control chamber is also expected, as it indicates that suction is being applied. Drainage of 100 mL in the first hour may be normal, depending on the client’s condition.

Question 9

A nurse is assessing a client who is experiencing dyspnea. Which of the following findings is a late sign of hypoxia?

a. Cyanosis
b. Restlessness
c. Tachycardia
d. Confusion

Answer 9

a. Cyanosis

Rationale:
Cyanosis, a bluish discoloration of the skin and mucous membranes, is a late sign of hypoxia. Restlessness, tachycardia, and confusion are earlier signs of hypoxia.

Question 10

Question 10:
Which of the following conditions can cause respiratory acidosis?

a. Hyperventilation
b. Hypoventilation
c. Anxiety
d. Pain

Answer 10

b. Hypoventilation

Rationale:
Hypoventilation, or inadequate alveolar ventilation, leads to a buildup of carbon dioxide in the blood, resulting in respiratory acidosis. Hyperventilation causes respiratory alkalosis. Anxiety and pain can cause hyperventilation, potentially leading to respiratory alkalosis.

Question 11

A nurse is caring for a client who is experiencing a severe asthma attack. Which of the following medications should the nurse expect to administer first?

a. Albuterol
b. Ipratropium bromide
c. Corticosteroids
d. Oxygen

Answer 11

a. Albuterol

Rationale:
Albuterol is a short-acting bronchodilator that rapidly relieves bronchospasm during an asthma attack. Ipratropium bromide is another bronchodilator that can be used in combination with albuterol. Corticosteroids reduce inflammation but have a delayed onset of action. Oxygen is important to address hypoxemia but does not directly relieve bronchospasm.

Question 12

A nurse is caring for a client who has a pulmonary embolism. Which of the following findings should the nurse expect?

a. Sudden onset of chest pain
b. Shortness of breath
c. Tachycardia
d. All of the above

Answer 12

d. All of the above

Rationale:
These findings are common in clients with a pulmonary embolism. A pulmonary embolism is a blockage of an artery in the lungs, often caused by a blood clot that travels from the legs. The blockage restricts blood flow to the lungs, causing chest pain, shortness of breath, and tachycardia.

Question 13

A nurse is caring for a client who is receiving oxygen therapy. Which of the following actions should the nurse take to ensure the client’s safety?

a. No smoking signs should be posted in the client’s room.
b. Electrical equipment should be grounded.
c. Oxygen cylinders should be stored upright. d. All of the above

Answer 13

d. All of the above

Rationale:
Oxygen is flammable and supports combustion. All of these actions are important to prevent fires and explosions when oxygen is in use.

Question 14

A nurse is caring for a client who has a pneumothorax. Which of the following actions should the nurse expect to take?

a. Prepare the client for a chest tube insertion.
b. Administer oxygen as prescribed.
c. Monitor the client’s vital signs and respiratory status.
d. All of the above

Answer 14

d. All of the above

Rationale:
A pneumothorax is a collapsed lung caused by air in the pleural space. A chest tube is inserted to remove the air and re-expand the lung. Oxygen therapy is administered to improve oxygenation. Vital signs and respiratory status are closely monitored to assess the client’s condition.

Question 15

A nurse is caring for a client who has pneumonia. Which of the following interventions should the nurse include in the client’s plan of care?

a. Encourage deep breathing and coughing. b. Administer antibiotics as prescribed.
c. Monitor the client’s temperature and oxygen saturation.
d. All of the above

Answer 15

d. All of the above

Rationale:
Pneumonia is an infection of the lungs that causes inflammation and fluid buildup. Deep breathing and coughing help to clear secretions and prevent atelectasis. Antibiotics are used to treat the infection. Temperature and oxygen saturation are monitored to assess the client’s response to treatment.

Question 16

A nurse is caring for a client who has a history of deep vein thrombosis (DVT). Which of the following instructions should the nurse provide to the client to prevent a recurrence of DVT?

a. Elevate the legs when sitting or lying down.
b. Wear compression stockings as prescribed.
c. Engage in regular physical activity.
d. All of the above

Answer 16

d. All of the above

Rationale:
Deep vein thrombosis is a blood clot in a deep vein, usually in the legs. These measures help to improve blood flow and reduce the risk of clot formation. Elevating the legs promotes venous return. Compression stockings apply pressure to the legs, preventing blood from pooling. Physical activity enhances circulation.

Question 17

A nurse is caring for a client who has a history of heart failure. Which of the following findings should the nurse report to the provider immediately?

a. Weight gain of 2 pounds in one day
b. Increased shortness of breath
c. Swelling in the legs and ankles
d. All of the above

Answer 17

d. All of the above

Rationale:
These findings are signs of worsening heart failure. Weight gain is due to fluid retention. Shortness of breath indicates that the heart is struggling to pump effectively. Swelling in the legs and ankles is caused by fluid buildup.

Question 18

A nurse is caring for a client who is experiencing a myocardial infarction (MI). Which of the following actions should the nurse take first?

a. Administer oxygen as prescribed.
b. Assess the client’s pain and administer pain medication.
c. Obtain a 12-lead electrocardiogram (ECG). d. Notify the provider.

Answer 18

a. Administer oxygen as prescribed.

Rationale:
Oxygen therapy is the priority intervention for a client experiencing an MI. It helps to improve oxygenation to the damaged heart muscle. Pain assessment, pain medication, ECG, and notification of the provider are all important actions, but addressing the client’s oxygenation needs is the most urgent.

Question 19

A nurse is caring for a client who has a history of hypertension. Which of the following lifestyle modifications should the nurse encourage the client to make?

a. Reduce sodium intake b. Engage in regular physical activity
c. Maintain a healthy weight
d. All of the above

Answer 19

d. All of the above

Rationale:
These lifestyle modifications help to lower blood pressure and manage hypertension. Reducing sodium intake lowers fluid retention, which can contribute to high blood pressure. Physical activity strengthens the heart and improves blood flow. Maintaining a healthy weight reduces strain on the cardiovascular system.

Question 20

A nurse is caring for a client who has a history of atrial fibrillation. Which of the following medications should the nurse expect the client to be prescribed?

a. Anticoagulants
b. Beta-blockers
c. Digoxin
d. All of the above

Answer 20

d. All of the above

Rationale:
Atrial fibrillation is an irregular heart rhythm that increases the risk of stroke. Anticoagulants are used to prevent blood clots that can lead to stroke. Beta-blockers help to control heart rate. Digoxin can be used to regulate hear

Question 21

A client with a history of COPD is admitted to the hospital with a diagnosis of pneumonia. The client is receiving oxygen therapy via nasal cannula at a flow rate of 2 L/min. Which of the following nursing interventions is appropriate?

a. Encourage the client to cough and deep breathe every hour.
b. Monitor the client’s oxygen saturation levels continuously.
c. Suction the client’s airway every 2 hours to maintain patency.
d. Restrict the client’s fluid intake to prevent fluid overload.

Answer 21

a. Encourage the client to cough and deep breathe every hour.

Rationale:
Encouraging coughing and deep breathing helps to mobilize secretions and prevent atelectasis, which is particularly important in clients with pneumonia and COPD. Continuous oxygen saturation monitoring may not be necessary for stable clients on low-flow oxygen. Suctioning should only be performed when clinically indicated, as excessive suctioning can irritate the airways and increase the risk of infection. Fluid restriction is not generally indicated for clients with pneumonia unless there is evidence of fluid overload.

Question 22

A nurse is providing discharge teaching to a client who has been newly diagnosed with asthma. Which of the following statements by the client indicates a need for further teaching?

a. “I will avoid triggers that I know worsen my asthma symptoms.”
b. “I will carry my rescue inhaler with me at all times.”
c. “I will use my peak flow meter only when I am having an asthma attack.” d. “I will take my controller medications as prescribed, even when I am feeling well.”

Answer 22

c. “I will use my peak flow meter only when I am having an asthma attack.”

Rationale:
Peak flow meters should be used regularly, even when the client is asymptomatic, to monitor lung function and detect early signs of worsening asthma. Avoiding triggers, carrying a rescue inhaler, and adhering to controller medications are all important aspects of asthma management.

Question 23

A nurse is caring for a client who is postoperative following a thoracotomy. Which of the following assessment findings should the nurse report to the provider immediately?

a. Serosanguineous drainage from the chest tube
b. Pain at the incision site c. Tracheal deviation
d. Decreased breath sounds on the operative side

Answer 23

c. Tracheal deviation

Rationale:
Tracheal deviation is a sign of a tension pneumothorax, a life-threatening condition that requires immediate intervention. Serosanguineous drainage from the chest tube is expected after a thoracotomy. Pain at the incision site is also anticipated and can be managed with analgesics. Decreased breath sounds on the operative side may be normal due to postoperative pain and splinting, but it should be monitored closely.

Question 24

A nurse is caring for a client who is receiving oxygen therapy via a non-rebreather mask. Which of the following actions should the nurse take?

a. Ensure that the reservoir bag remains deflated during inhalation.
b. Adjust the flow rate to maintain a minimum of 10 L/min.
c. Monitor the client for signs of skin breakdown around the mask.
d. Encourage the client to remove the mask when eating or drinking.

Answer 24

c. Monitor the client for signs of skin breakdown around the mask.

Rationale:
The non-rebreather mask delivers high concentrations of oxygen and can cause skin irritation if not properly fitted and monitored. The reservoir bag should remain inflated during inhalation. The flow rate should be adjusted to maintain the prescribed oxygen concentration, typically between 10-15 L/min but may vary. Clients receiving oxygen via a non-rebreather mask should not remove the mask when eating or drinking, as this would interrupt oxygen delivery.

Question 25

A nurse is caring for a client who has a history of sleep apnea. Which of the following interventions should the nurse expect to be included in the client’s plan of care?

a. Continuous positive airway pressure (CPAP) therapy
b. Weight loss if overweight
c. Avoidance of alcohol and sedatives before bedtime
d. All of the above

Answer 25

d. All of the above

Rationale:
Sleep apnea is a condition characterized by repeated pauses in breathing during sleep. CPAP therapy helps to keep the airway open during sleep. Weight loss can reduce the severity of sleep apnea in overweight individuals. Alcohol and sedatives worsen sleep apnea by relaxing the muscles that control breathing.

Question 26

A nurse is assessing a client who is experiencing shortness of breath. Which of the following positions should the nurse place the client in to facilitate breathing?

a. Supine
b. Prone
c. High Fowler’s
d. Trendelenburg

Answer 26

c. High Fowler’s

Rationale:
High Fowler’s position, where the head of the bed is elevated to 60-90 degrees, allows for maximum lung expansion and reduces pressure on the diaphragm, facilitating breathing. Supine, prone, and Trendelenburg positions can impair breathing by restricting chest expansion.

Question 27

A nurse is caring for a client who has a history of pulmonary hypertension. Which of the following medications should the nurse expect the client to be prescribed?

a. Diuretics
b. Vasodilators
c. Oxygen
d. All of the above

Answer 27

d. All of the above

Rationale:
Pulmonary hypertension is high blood pressure in the arteries of the lungs. Diuretics help to reduce fluid buildup in the lungs, decreasing pressure. Vasodilators relax and widen blood vessels, lowering blood pressure. Oxygen therapy improves oxygenation to the lungs.

Question 28

A nurse is caring for a client who has a history of cystic fibrosis. Which of the following interventions should the nurse include in the client’s plan of care?

a. Chest physiotherapy
b. Airway clearance techniques
c. Pancreatic enzyme replacement therapy
d. All of the above

Answer 28

d. All of the above

Rationale:
Cystic fibrosis is a genetic disorder that affects the lungs, pancreas, and other organs. Chest physiotherapy helps to loosen and remove mucus from the lungs. Airway clearance techniques, such as coughing and postural drainage, also aid in mucus removal. Pancreatic enzyme replacement therapy is necessary because cystic fibrosis impairs pancreatic function, leading to digestive problems.

Question 29

A nurse is caring for a client who has a history of emphysema. Which of the following oxygen delivery systems would be most appropriate for this client?

a. Nasal cannula
b. Venturi mask
c. Non-rebreather mask
d. Simple face mask

Answer 29

b. Venturi mask

Rationale:
The Venturi mask allows for precise delivery of oxygen concentrations, which is important for clients with emphysema who are sensitive to high oxygen levels. Nasal cannulae provide low-flow oxygen, which may be insufficient for clients with emphysema. Non-rebreather masks deliver high concentrations of oxygen, which can suppress the respiratory drive in clients with emphysema. Simple face masks do not provide precise control over oxygen concentrations.

Question 30

A nurse is caring for a client who is experiencing respiratory distress. Which of the following findings indicates that the client’s condition is worsening?

a. Respiratory rate of 12 breaths per minute
b. Use of accessory muscles to breathe
c. Oxygen saturation of 98%
d. Clear lung sounds on auscultation

Answer 30

b. Use of accessory muscles to breathe

Rationale:
The use of accessory muscles to breathe, such as the neck and shoulder muscles, is a sign of increased work of breathing and suggests worsening respiratory distress. A respiratory rate of 12 breaths per minute is within the normal range. Oxygen saturation of 98% indicates adequate oxygenation. Clear lung sounds are a normal finding.

Question 31

A nurse is assessing a client with suspected pulmonary edema. Which of the following breath sounds are characteristic of this condition?

a. Wheezes
b. Stridor
c. Crackles
d. Rhonchi

Answer 31

c. Crackles

Rationale:
Crackles, also known as rales, are fine, bubbling sounds heard on inspiration and are characteristic of fluid in the alveoli, as seen in pulmonary edema. Wheezes are high-pitched whistling sounds associated with airway narrowing. Stridor is a harsh, high-pitched sound indicating upper airway obstruction. Rhonchi are coarse, rattling sounds caused by secretions in the airways.

Question 32

A nurse is caring for a client who is postoperative following a tonsillectomy. Which of the following findings should the nurse report to the provider immediately?

a. Frequent swallowing
b. Sore throat
c. Low-grade fever
d. Bright red blood draining from the mouth

Answer 32

d. Bright red blood draining from the mouth

Rationale:
Bright red blood draining from the mouth is a sign of active bleeding, which is a complication following a tonsillectomy and requires immediate attention. Frequent swallowing, sore throat, and low-grade fever are expected findings after a tonsillectomy.

Question 33

A nurse is caring for a client who has a history of tuberculosis. Which of the following precautions should the nurse implement?

a. Airborne precautions
b. Droplet precautions
c. Contact precautions
d. Standard precautions

Answer 33

a. Airborne precautions

Rationale:
Tuberculosis is spread through the air via droplets that can remain suspended for extended periods. Airborne precautions, including wearing an N95 respirator, are necessary to prevent transmission. Droplet precautions are used for infections spread through larger droplets that travel shorter distances. Contact precautions are for infections spread through direct contact. Standard precautions are used for all clients to prevent the spread of infections

Question 34

A nurse is caring for a client who is experiencing a tension pneumothorax. Which of the following actions should the nurse take first?

a. Administer oxygen
b. Prepare for a chest tube insertion
c. Perform a needle thoracostomy
d. Obtain a chest x-ray

Answer 34

c. Perform a needle thoracostomy

Rationale:
A tension pneumothorax is a life-threatening condition where air trapped in the pleural space compresses the lung and shifts mediastinal structures. Immediate decompression is required to relieve the pressure. A needle thoracostomy, the insertion of a large-bore needle into the pleural space, is the fastest way to achieve decompression. While oxygen administration and chest tube insertion are necessary, they are not as immediate as needle thoracostomy. Obtaining a chest x-ray is not a priority in this situation as the diagnosis is usually clinically apparent.

Question 35

A nurse is caring for a client who has a history of asthma and is experiencing an acute asthma attack. The client is receiving albuterol via nebulizer. Which of the following findings indicates that the treatment is effective?

a. Decreased wheezing
b. Increased respiratory rate
c. Decreased oxygen saturation
d. Increased heart rate

Answer 35

a. Decreased wheezing

Rationale:
Albuterol is a bronchodilator that relaxes airway muscles, relieving bronchospasm and reducing wheezing. An increased respiratory rate, decreased oxygen saturation, and increased heart rate are signs of worsening respiratory distress and indicate that the treatment is not effective.

Question 36

A nurse is caring for a client who is experiencing acute respiratory distress syndrome (ARDS). Which of the following ventilator settings should the nurse expect to see?

a. High tidal volume
b. Low positive end-expiratory pressure (PEEP)
c. High respiratory rate
d. Low oxygen concentration (FiO2)

Answer 36

a. High tidal volume

Rationale:
ARDS is characterized by severe lung injury and impaired gas exchange. High tidal volumes are often used to improve ventilation and oxygenation in clients with ARDS. PEEP is used to keep alveoli open at the end of expiration and is usually set at higher levels in ARDS. The respiratory rate is typically adjusted to maintain adequate ventilation while minimizing lung injury. High oxygen concentrations (FiO2) are used to address hypoxemia.

Question 37

A nurse is caring for a client who has a history of chronic bronchitis. Which of the following lifestyle modifications should the nurse encourage the client to make?

a. Smoking cessation
b. Regular exercise
c. Weight management
d. All of the above

Answer 37

d. All of the above

Rationale:
Chronic bronchitis is a type of COPD characterized by inflammation and mucus buildup in the airways. Smoking cessation is crucial to prevent further lung damage. Regular exercise improves lung function and overall health. Weight management reduces strain on the respiratory system.

Question 38

A nurse is caring for a client who has a history of emphysema and is receiving oxygen therapy at a flow rate of 2 L/min via nasal cannula. The client’s oxygen saturation level is 88%. Which of the following actions should the nurse take?

a. Increase the oxygen flow rate to 4 L/min
b. Contact the respiratory therapist for a ventilator assessment
c. Place the client in a high Fowler’s position
d. Continue to monitor the client’s oxygen saturation levels

Answer 38

c. Place the client in a high Fowler’s position

Rationale:
Placing the client in a high Fowler’s position helps to maximize lung expansion and improve oxygenation. While increasing the oxygen flow rate may be considered, it’s important to note that clients with emphysema can be sensitive to high oxygen levels, which can suppress their respiratory drive. Contacting the respiratory therapist for a ventilator assessment may be premature at this point. Continuing to monitor the client’s oxygen saturation levels is appropriate but does not address the immediate need to improve oxygenation.

Question 39

A nurse is caring for a client who has a chest tube connected to a water-seal drainage system. The nurse observes continuous bubbling in the water-seal chamber. Which of the following actions should the nurse take?

a. Clamp the chest tube immediately
b. Check the connections for leaks
c. Add more water to the water-seal chamber
d. Document the findings as normal

Answer 39

b. Check the connections for leaks

Rationale:
Continuous bubbling in the water-seal chamber indicates an air leak in the system. The nurse should systematically check all connections and tubing for leaks and tighten them as necessary. Clamping the chest tube could create a tension pneumothorax and is contraindicated. Adding more water to the water-seal chamber will not resolve the air leak. Continuous bubbling in the water-seal chamber is not a normal finding and should be addressed promptly.

Question 40

A nurse is caring for a client who is receiving mechanical ventilation. The client’s endotracheal tube is accidentally dislodged. Which of the following actions should the nurse take first?

a. Attempt to reinsert the endotracheal tube
b. Ventilate the client with a bag-valve mask device
c. Call for assistance
d. Assess the client’s vital signs

Answer 40

c. Call for assistance

Rationale:
When an endotracheal tube is dislodged, the priority is to establish a patent airway. The nurse should immediately call for assistance from the respiratory therapist or other qualified healthcare professionals who can reinsert the endotracheal tube. While ventilating the client with a bag-valve mask device and assessing vital signs are important actions, calling for assistance is the most critical initial step to ensure timely reintubation.

Question 41

A client presents to the emergency department with sudden onset of shortness of breath, chest pain, and tachycardia. The nurse suspects a pulmonary embolism. Which of the following diagnostic tests would be most helpful in confirming this diagnosis?

a. Chest x-ray
b. Computed tomography pulmonary angiography (CTPA)
c. Electrocardiogram (ECG)
d. Complete blood count (CBC)

Answer 41

b. Computed tomography pulmonary angiography (CTPA)

Rationale:
CTPA is the gold standard diagnostic test for pulmonary embolism. It provides detailed images of the pulmonary arteries, allowing for visualization of any clots. Chest x-ray, ECG, and CBC may show nonspecific findings in pulmonary embolism but are not as definitive as CTPA.

Question 42

A nurse is caring for a client who has been diagnosed with pleural effusion. Which of the following procedures would be performed to remove fluid from the pleural space?

a. Bronchoscopy
b. Thoracentesis
c. Chest tube insertion
d. Pulmonary function tests

Answer 42

b. Thoracentesis

Rationale:
Thoracentesis is a procedure in which a needle is inserted into the pleural space to aspirate fluid. Bronchoscopy is used to visualize the airways. Chest tube insertion is performed to drain air or fluid from the pleural space but is typically used for larger volumes of fluid. Pulmonary function tests assess lung function but do not involve fluid removal.

Question 43

A nurse is caring for a client who has a history of heart failure. The client is prescribed a low-sodium diet. Which of the following food choices by the client indicates a need for further teaching?

a. Grilled chicken breast with steamed vegetables b. Canned soup with crackers
c. Fresh fruit salad with yogurt
d. Baked potato with unsalted butter

Answer 43

b. Canned soup with crackers

Rationale:
Canned soups are often high in sodium and should be avoided on a low-sodium diet. Grilled chicken breast with steamed vegetables, fresh fruit salad with yogurt, and baked potato with unsalted butter are all low-sodium food choices.

Question 44

A nurse is caring for a client who has a history of peripheral arterial disease (PAD). Which of the following findings should the nurse expect to assess in the client’s lower extremities?

a. Edema
b. Hair loss
c. Warm skin
d. Bounding pulses

Answer 44

b. Hair loss

Rationale:
PAD is characterized by narrowing of the arteries in the legs and feet, leading to decreased blood flow. Hair loss, cool skin, and weak or absent pulses are common findings in clients with PAD. Edema is more common in venous insufficiency. Warm skin and bounding pulses indicate adequate blood flow.

Question 45

A nurse is caring for a client who is experiencing a myocardial infarction (MI). Which of the following laboratory tests would be most indicative of myocardial damage?

a. Troponin
b. Creatinine
c. Potassium
d. Hemoglobin

Answer 45

a. Troponin

Rationale:
Troponin is a protein released into the bloodstream when heart muscle cells are damaged, making it a specific marker for MI. Creatinine is a marker of kidney function. Potassium is an electrolyte that can be affected by various conditions, including heart problems. Hemoglobin is a protein in red blood cells that carries oxygen.

Question 46

A nurse is providing discharge teaching to a client who has been diagnosed with hypertension. Which of the following statements by the client indicates an understanding of the teaching?

a. “I can stop taking my medication if my blood pressure is normal.”
b. “I should limit my alcohol intake to no more than two drinks per day.” c. “I should avoid strenuous exercise as it can raise my blood pressure.”
d. “I will take my medications as prescribed, even when I am feeling well.”

Answer 46

d. “I will take my medications as prescribed, even when I am feeling well.”

Rationale:
Hypertension often has no symptoms, so clients need to understand the importance of adhering to their medication regimen even when they feel healthy. Stopping medication without healthcare provider guidance can lead to dangerous blood pressure fluctuations. Limiting alcohol intake and engaging in regular exercise are generally recommended for individuals with hypertension. Strenuous exercise should be approached gradually and with healthcare provider approval.

Question 47

A nurse is caring for a client who has a history of deep vein thrombosis (DVT) and is prescribed heparin therapy. Which of the following laboratory tests should the nurse monitor to evaluate the effectiveness of the heparin therapy?

a. Prothrombin time (PT) and international normalized ratio (INR)
b. Partial thromboplastin time (PTT)
c. Platelet count
d. Hemoglobin and hematocrit

Answer 47

b. Partial thromboplastin time (PTT)

Rationale:
PTT is a blood test that measures the time it takes for blood to clot, which is prolonged by heparin. PT and INR are used to monitor warfarin therapy. Platelet count is important to monitor for heparin-induced thrombocytopenia. Hemoglobin and hematocrit reflect red blood cell levels and are not specific to heparin therapy monitoring

Question 48

A nurse is assessing a client who is experiencing an asthma attack. Which of the following findings is a priority for the nurse to address?

a. Cough
b. Wheezing
c. Dyspnea
d. Anxiety

Answer 48

c. Dyspnea

Rationale:
Dyspnea, or shortness of breath, is a priority finding in an asthma attack as it indicates airway obstruction and impaired gas exchange. While cough, wheezing, and anxiety are also common symptoms, dyspnea poses the most immediate threat to the client’s respiratory status.

Question 49

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The client’s nares are dry and irritated. Which of the following interventions should the nurse implement?

a. Apply petroleum jelly to the client’s nares
b. Increase the oxygen flow rate
c. Humidify the oxygen
d. Discontinue the nasal cannula and switch to a face mask

Answer 49

c. Humidify the oxygen

Rationale:
Humidifying oxygen helps to prevent dryness and irritation of the nasal passages. Petroleum jelly should not be used near oxygen as it is flammable. Increasing the oxygen flow rate will not address the dryness and may not be necessary. Switching to a face mask may not be necessary if humidification can resolve the issue.

Question 50

A nurse is caring for a client who is postoperative following a coronary artery bypass graft (CABG) surgery. The client’s chest tube output has suddenly increased from 50 mL/hour to 200 mL/hour. Which of the following actions should the nurse take first?

a. Notify the surgeon immediately
b. Assess the client’s vital signs and respiratory status
c. Check the chest tube drainage system for leaks d. Document the findings and continue to monitor

Answer 50

b. Assess the client’s vital signs and respiratory status

Rationale:
While a sudden increase in chest tube output can be concerning, the nurse’s first action should be to assess the client’s overall condition, including vital signs and respiratory status. This will help determine the urgency of the situation and guide further actions. Notifying the surgeon, checking for leaks, and documenting the findings are all important but should be done after assessing the client’s immediate stability.