Question 1

A client is unable to breathe independently and is now on mechanical ventilation. Which of the following is a correct nursing intervention for maintenance?

Accepted Answer

A) Keep the head of the bed flat for 6 hours. 
B) Avoid using mouth rinses or mouthwashes. 
C) Provide the client with a paper and pencil or letter board. 
D) Drain condensation into the humidifier when it collects in the tubing. 
A) Keep the head of the bed flat for 6 hours. 
B) Avoid using mouth rinses or mouthwashes. 
C) Provide the client with a paper and pencil or letter board. 
D) Drain condensation into the humidifier when it collects in the tubing.

Question 2

The nurse is preparing to obtain sputum specimens from several clients. Which of the following clients could the nurse collect a sputum specimen without using a suction catheter?

Accepted Answer

A) The client with a newly placed tracheostomy 
B) The client with an endotracheal tube 
C) The client with late-stage amyotrophic lateral sclerosis 
D) The client admitted with chronic bronchitis 
A) The client with a newly placed tracheostomy 
B) The client with an endotracheal tube 
C) The client with late-stage amyotrophic lateral sclerosis 
D) The client admitted with chronic bronchitis

Question 3

The nurse admits a client to the surgical unit from the postanesthesia care unit. The client has an oral airway in place and awakens only to painful stimuli. What is the priority nursing action?

Accepted Answer

A) Remove the oral airway, and elevate the head of the bed. 
B) Position the client with the head turned to the side. 
C) Measure vital signs, and check surgical dressing. 
D) Call the surgeon, and obtain postoperative prescriptions. 
A) Remove the oral airway, and elevate the head of the bed. 
B) Position the client with the head turned to the side. 
C) Measure vital signs, and check surgical dressing. 
D) Call the surgeon, and obtain postoperative prescriptions.

Question 4

The nurse is administering a purified protein derivative (PPD) test to a nursing student. Which of the following statements concerning PPD testing is true?

Accepted Answer

A) A positive reaction indicates that the client has active tuberculosis (T
B) . 
B) A positive reaction indicates that the client has been exposed to the disease. 
C) A negative reaction always excludes the diagnosis of TB. 
D) The PPD can be read within 12 to 24 hours after the injection. 
A) A positive reaction indicates that the client has active tuberculosis (T
B) . 
B) A positive reaction indicates that the client has been exposed to the disease. 
C) A negative reaction always excludes the diagnosis of TB. 
D) The PPD can be read within 12 to 24 hours after the injection.

Question 5

The nurse is admitting to the medical-surgical unit an older adult with a diagnosis of pulmonary hypertension and right-sided heart failure. The client is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take?

Accepted Answer

A) Review and implement the primary care provider's prescriptions for treatments. 
B) Perform a quick physical examination of breathing, circulation, and oxygenation. 
C) Gather a thorough medical history, including current symptoms, from the family. 
D) Administer supplemental oxygen to the client through a nasal cannula. 
A) Review and implement the primary care provider's prescriptions for treatments. 
B) Perform a quick physical examination of breathing, circulation, and oxygenation. 
C) Gather a thorough medical history, including current symptoms, from the family. 
D) Administer supplemental oxygen to the client through a nasal cannula.

Question 6

While a client is receiving hygiene care, the chest tube becomes disconnected from the water-seal chest drainage unit (CDU). Which action should the nurse take immediately?

Accepted Answer

A) Clamp the chest tube close to the insertion site with rubber-shod hemostats. 
B) Set up a new drainage system, and quickly connect it to the chest tube. 
C) Have the client take a deep breath while the nurse reconnects the tube to the CDU. 
D) Place the disconnected end nearest the client into a bottle of sterile water. 
A) Clamp the chest tube close to the insertion site with rubber-shod hemostats. 
B) Set up a new drainage system, and quickly connect it to the chest tube. 
C) Have the client take a deep breath while the nurse reconnects the tube to the CDU. 
D) Place the disconnected end nearest the client into a bottle of sterile water.

Question 7

The client was admitted to the intensive care unit (ICU) for respiratory acidosis secondary to smoke inhalation and exposure to caustic gases. After placement of an endotracheal tube and connection to a mechanical ventilator, the arterial blood gas results are pH = 7.28; partial pressure of oxygen (PaO2) = 85; partial pressure of carbon dioxide (PaCO2) = 60. What changes to care does the nurse anticipate?

Accepted Answer

A) Wean the client from the ventilator. 
B) Increase the concentration of oxygen delivered. 
C) Decrease the concentration of oxygen delivered. 
D) Increase the number of breaths per minute on the ventilator. 
A) Wean the client from the ventilator. 
B) Increase the concentration of oxygen delivered. 
C) Decrease the concentration of oxygen delivered. 
D) Increase the number of breaths per minute on the ventilator.

Question 8

When using sterile technique to perform care of a new tracheostomy, which of the following is correct?

Accepted Answer

A) Cleanse the area with hot soapy water, and rinse well. 
B) Place the client in semi-Fowler's position, if possible. 
C) Clean the stoma under the faceplate with hydrogen peroxide. 
D) Cut a slit in sterile 4 * 4 inch gauze halfway through to make a dressing. 
A) Cleanse the area with hot soapy water, and rinse well. 
B) Place the client in semi-Fowler's position, if possible. 
C) Clean the stoma under the faceplate with hydrogen peroxide. 
D) Cut a slit in sterile 4 * 4 inch gauze halfway through to make a dressing.

Question 9

The nurse administers an antitussive/expectorant cough preparation to a client with bronchitis. Which of the following responses indicates to the nurse that the medication is effective?

Accepted Answer

A) The amount of sputum the client expectorates decreases with each dose administered. 
B) Cough is completely suppressed, and the client is able to sleep through the night. 
C) Dry, unproductive cough is reduced, but her voluntary coughing is more productive. 
D) Involuntary coughing produces large amounts of thick yellow sputum. 
A) The amount of sputum the client expectorates decreases with each dose administered. 
B) Cough is completely suppressed, and the client is able to sleep through the night. 
C) Dry, unproductive cough is reduced, but her voluntary coughing is more productive. 
D) Involuntary coughing produces large amounts of thick yellow sputum.

Question 10

The nurse is caring for a 6-month-old infant diagnosed with respiratory syncytial virus (RSV) infection. What consideration will most influence the nurse's plan of care?

Accepted Answer

A) Infants breathe more rapidly than adults. 
B) Infants' airways are narrower and easily obstructed. 
C) Infants' lower hemoglobin (Hg
B)  levels reduce oxygenation. 
D) Infants have larger tonsils and adenoids. 
A) Infants breathe more rapidly than adults. 
B) Infants' airways are narrower and easily obstructed. 
C) Infants' lower hemoglobin (Hg
B)  levels reduce oxygenation. 
D) Infants have larger tonsils and adenoids.

Question 11

The nurse is caring for a client requiring a mechanical ventilator. When checking the inline thermometer, the nurse finds what temperature acceptable?

Accepted Answer

A) 78°F 
B) 84°F 
C) 96°F 
D) 105°F 
A) 78°F 
B) 84°F 
C) 96°F 
D) 105°F

Question 12

A nurse is suctioning a client via an open system tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of:

Accepted Answer

A) 5 seconds 
B) 15 seconds 
C) 30 seconds 
D) 45 seconds 
A) 5 seconds 
B) 15 seconds 
C) 30 seconds 
D) 45 seconds

Question 13

The nurse is counseling a 17-year-old girl on smoking cessation. The nurse should include which of the following helpful tips in her education? Select all that apply.

Accepted Answer

A) "Keep healthy snacks or gum available to chew instead of smoking a cigarette." 
B) "Don't tell anyone that you are trying to quit until you are confident of your success." 
C) "Plan a time to quit when you will not have many other demands or stressors in your life." 
D) "Reward yourself with an activity you enjoy when you quit smoking." 
E) "Ask your physician for a prescription for smoking cessation medications." 
A) "Keep healthy snacks or gum available to chew instead of smoking a cigarette." 
B) "Don't tell anyone that you are trying to quit until you are confident of your success." 
C) "Plan a time to quit when you will not have many other demands or stressors in your life." 
D) "Reward yourself with an activity you enjoy when you quit smoking." 
E) "Ask your physician for a prescription for smoking cessation medications."

Question 14

Which of the following best describes the function of type 1 alveolar cells?

Accepted Answer

A) They add moisture to the inhaled air in the lungs. 
B) They open the airway during breathing to allow air to move. 
C) They facilitate gas exchange in the lungs. 
D) They produce surfactant to lubricate the lungs. 
A) They add moisture to the inhaled air in the lungs. 
B) They open the airway during breathing to allow air to move. 
C) They facilitate gas exchange in the lungs. 
D) They produce surfactant to lubricate the lungs.

Question 15

The student nurse observes the staff nurse providing care to a client with a chest tube. Which of the nurse's actions should the student recognize as incorrect and report to the nursing instructor?

Accepted Answer

A) Recording drainage from chest tube as output 
B) Securing the chest tube to the chest tube dressing 
C) Checking the water seal chamber for bubbling 
D) Milking the chest tube to promote drainage 
A) Recording drainage from chest tube as output 
B) Securing the chest tube to the chest tube dressing 
C) Checking the water seal chamber for bubbling 
D) Milking the chest tube to promote drainage

Question 16

Of the following interventions, which of the following may reduce the risk of postoperative atelectasis? Select all that apply.

Accepted Answer

A) Administer bronchodilators. 
B) Apply low-flow oxygen. 
C) Encourage coughing and deep breathing. 
D) Administer pain medication. 
E) Suction the airway prn (as needed). 
A) Administer bronchodilators. 
B) Apply low-flow oxygen. 
C) Encourage coughing and deep breathing. 
D) Administer pain medication. 
E) Suction the airway prn (as needed).

Exam 36: Oxygenation

A client is unable to breathe independently and is now on mechanical ventilation. Which of the following is a correct nursing intervention for maintenance?

The nurse is preparing to obtain sputum specimens from several clients. Which of the following clients could the nurse collect a sputum specimen without using a suction catheter?

The nurse admits a client to the surgical unit from the postanesthesia care unit. The client has an oral airway in place and awakens only to painful stimuli. What is the priority nursing action?

The nurse is administering a purified protein derivative (PPD) test to a nursing student. Which of the following statements concerning PPD testing is true?

The nurse is admitting to the medical-surgical unit an older adult with a diagnosis of pulmonary hypertension and right-sided heart failure. The client is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take?

While a client is receiving hygiene care, the chest tube becomes disconnected from the water-seal chest drainage unit (CDU). Which action should the nurse take immediately?

When using sterile technique to perform care of a new tracheostomy, which of the following is correct?

The nurse administers an antitussive/expectorant cough preparation to a client with bronchitis. Which of the following responses indicates to the nurse that the medication is effective?

The nurse is caring for a 6-month-old infant diagnosed with respiratory syncytial virus (RSV) infection. What consideration will most influence the nurse's plan of care?

The nurse is caring for a client requiring a mechanical ventilator. When checking the inline thermometer, the nurse finds what temperature acceptable?

A nurse is suctioning a client via an open system tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of:

The nurse is counseling a 17-year-old girl on smoking cessation. The nurse should include which of the following helpful tips in her education? Select all that apply.

Which of the following best describes the function of type 1 alveolar cells?

The student nurse observes the staff nurse providing care to a client with a chest tube. Which of the nurse's actions should the student recognize as incorrect and report to the nursing instructor?

Of the following interventions, which of the following may reduce the risk of postoperative atelectasis? Select all that apply.

Evolution of Nursing Thought Action

Assessment

Analysisdiagnosis

Planning Outcomes

Planning Interventions

Implementation Evaluation

Theory, Research, Evidence-Based Practice

Life Span: Infancy Through Middle Adulthood

Life Span: Older Adults

Experiencing Health Illness

Stress Adaptation

Psychosocial Health Illness

The Family

Culture Ethnicity

Spirituality

Loss, Grief, Dying

Documenting Reporting

Teaching Learning

Measuring Vital Signs

Communication Therapeutic Relationships

Health Assessment

Promoting Asepsis Preventing Infection

Promoting Safety

Facilitating Hygiene

Administering Medications

Nutrition

Urinary Elimination

Bowel Elimination

Sensation, Perception, Response

Pain

Physical Activity Immobility

Sexual Health

Sleep Rest

Skin Integrity Wound Healing

Circulation Perfusion

Fluids, Electrolytes, Acidbase Balance

Perioperative Care

Leading Managing

Nursing Informatics

Promoting Health

Community Home Health Nursing

Ethics Values

Legal Accountability

Holistic Healing

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