2021
TEST BANK
All Chapters Included
A college heath nurse interprets the peak expiratory flow rate for a student who has
asthma and fluids that student is in the yellow zone of his asthma action plan. The
nurse should base her actions on which of the following information? (select all
that apply.)
a. The nurse should use his quick-relief inhaler
b. The students asthma is not well controlled
c. The students peek flow is 50% to 80% of his best peak flow
d. The nurse should obtain a second expiratory flow rate
A nurse is caring for a client who is receiving mechanical ventilation and has an
ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which
of the following?
a. 480 mL (The average tidal volume is 7-9 (60kg x 8ml/kg =480)
A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube
in place and observes the absence of left-sided chest wall expansion upon
respiration. Which of the following complications should the nurse suspect?
a. Movement of the ET into the right main bronchus. ( During intubation the
staff can misplace the ET tube in the right stem bronchus. The nurse
should identify absence of chest wall movement or breath sounds on a
single sliding scale as indicating ET tube displacement, and should
notify appropriate personnel to reposition the tube)
A nurse is assessing the respiratory pattern of an older adult client who is receiving
end of life care. Which of the following assessment findings should the nurse
identify as Cheyne-stokes respirations?
a. Breathing ranging from very deep to very shallow with periods of apnea.
(The Cheyne-stokes respirations is an indication that the client is
approaching death.)
A nurse is caring for a client who is receiving mechanical ventilation via
, 2021
tracheostomy tube. The nurse should recognize that which of the following
complications is associated with long-term mechanical ventilation?
a. Stress ulcers (stress ulcers in clients who are receiving long-term
mechanical ventilation are caused by elevated levels of hydrochloric
acid in the stomach. Stress ulcers increase the risk for systemic
infections and require pharmacological treatment.)
A nurse is caring for a client following extubation of her endotracheal tube 10 min
ago. Which of the followings should the nurse report to the provider immediately?
a. Stridor
A nurse in an emergency department is planning care for a client who has a flail
chest on the right side following a MVA accident. Which of the following should
the nurse plan to take?
a. Prepare the client for positive pressure ventilation. (The nurse should
prepare the client for positive pressure ventilation to promote lung
expansion and stabilize the pressure within the clients chest. The nurse
should also administer analgesics to alleviate pain while breathing to
achieve lung re-expansion.)
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The
clients heart rate increases from 86/min to 110/min and becomes irregular. The
nurse should know that the client requires?
a. Pre-oxygination prior to suctioning. (Suctioning should be performed on
the endotracheal tube of a client who is mechanically ventilated to
remove accumulated secretions from the airways. Possible
complications of the procedure includes hypoxemia (Manifested by
tachycardia and arrhythmia) and tissue injury. An increased, irregular
heart rate while suctioning is evidence that the client is becoming
hypoxic. In preparation for suctioning, and to prevent hypoxemia the
client should be pre-oxyginated with a manual resusotator bag set at
100% oxygen)
A nurse is assessing a client immedietaly after the provider removes the clients
endotracheal tube. Which of the following findings should the nurse report to the
provider?
, 2021
a. Stridor
Alternating periods of hyperventilation and apnea is Cheyne-stokes breathing.
A nurse understands that there are three ways to decrease ventilator-assisted
pneumonia called a “ventilator bundle”. Which of the following three nursing
actions are included in the clients care bundle?
a. Hand hygiene, oral care, and HOB elevation
A nurse is caring for a client who has respiratory failure, is intubated, and is
mechanically ventilated. The client pulls out the edotrachial tube. Which of the
following is the priority action?
a. Ensure the airway is open
A nurse is assessing a clients wife how to take a blood pressure. Which of the
following actions by the wife indicates a need for further instructions?
a. Place the clients arm above the level of the heart
A nurse is monitoring a post-operative client who is unable to respond to questions.
Which of the following behviors should the nurse recognize as an indicator of
pain? (select all)
a. Resltlessness
b. Grimacing
c. Clenching
A nurse is assisting with the discharge plan of a client who has a permanent
tracheostomy. The nurse should verify the availability of which of the following
equipment? (select all)
a. Oxygen
b. Suction machine
c. Replacement canula
A nurse is giving shift report using SBAR to the oncoming nurse on a client who
has traumatic brain injury. When reporting information about the client, which of
the following are included in the situation of SBAR?
a. History of the injury
, 2021
SBAR examples:
1. Gaslow coma scales falls under assessment
2. Intercranial pressure readings falls under assessment
3. Medication that is needed falls under recommendations
A nurse is monitoring the cardiac output of a client who has left sided heart failure
using pulse pressure analysis. Which of the following findings can compromise the
reading?
a. The client is experiencing premature atrial contractions.
A nurse in the ICU is providing teaching for a client proior to the removal of an
endotracheal tube. Which of the following instructions should the nurse include in
the teaching?
a. Avoid speaking for long periods
A nurse is caring for a client who has severe head injuries and is declared brain
dead. The transplant coordinator has spoken with the clients family about organ
donation. The clients spouce states she is confused and does not know what she
should do. Which of the following responses by the nurse is appropriate?
a. What do you think your spouse would have wants?
A client is performing nasotrachial suctioning for a client who has COPD and an
artificial airway. Which of the following actions should the nurse take?
a. Preoxygenate the clients with 100% oxygen for up to 3 min.
A charge nurse has access to the faciliteies electronic records. It is appropriate for
the charge nurse to share her personal password with whom?
a. No one
A nurse is assessing a group of clients for hospice services. The nurse should
recommend hospice care for which of the following clients?
TEST BANK
All Chapters Included
A college heath nurse interprets the peak expiratory flow rate for a student who has
asthma and fluids that student is in the yellow zone of his asthma action plan. The
nurse should base her actions on which of the following information? (select all
that apply.)
a. The nurse should use his quick-relief inhaler
b. The students asthma is not well controlled
c. The students peek flow is 50% to 80% of his best peak flow
d. The nurse should obtain a second expiratory flow rate
A nurse is caring for a client who is receiving mechanical ventilation and has an
ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which
of the following?
a. 480 mL (The average tidal volume is 7-9 (60kg x 8ml/kg =480)
A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube
in place and observes the absence of left-sided chest wall expansion upon
respiration. Which of the following complications should the nurse suspect?
a. Movement of the ET into the right main bronchus. ( During intubation the
staff can misplace the ET tube in the right stem bronchus. The nurse
should identify absence of chest wall movement or breath sounds on a
single sliding scale as indicating ET tube displacement, and should
notify appropriate personnel to reposition the tube)
A nurse is assessing the respiratory pattern of an older adult client who is receiving
end of life care. Which of the following assessment findings should the nurse
identify as Cheyne-stokes respirations?
a. Breathing ranging from very deep to very shallow with periods of apnea.
(The Cheyne-stokes respirations is an indication that the client is
approaching death.)
A nurse is caring for a client who is receiving mechanical ventilation via
, 2021
tracheostomy tube. The nurse should recognize that which of the following
complications is associated with long-term mechanical ventilation?
a. Stress ulcers (stress ulcers in clients who are receiving long-term
mechanical ventilation are caused by elevated levels of hydrochloric
acid in the stomach. Stress ulcers increase the risk for systemic
infections and require pharmacological treatment.)
A nurse is caring for a client following extubation of her endotracheal tube 10 min
ago. Which of the followings should the nurse report to the provider immediately?
a. Stridor
A nurse in an emergency department is planning care for a client who has a flail
chest on the right side following a MVA accident. Which of the following should
the nurse plan to take?
a. Prepare the client for positive pressure ventilation. (The nurse should
prepare the client for positive pressure ventilation to promote lung
expansion and stabilize the pressure within the clients chest. The nurse
should also administer analgesics to alleviate pain while breathing to
achieve lung re-expansion.)
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The
clients heart rate increases from 86/min to 110/min and becomes irregular. The
nurse should know that the client requires?
a. Pre-oxygination prior to suctioning. (Suctioning should be performed on
the endotracheal tube of a client who is mechanically ventilated to
remove accumulated secretions from the airways. Possible
complications of the procedure includes hypoxemia (Manifested by
tachycardia and arrhythmia) and tissue injury. An increased, irregular
heart rate while suctioning is evidence that the client is becoming
hypoxic. In preparation for suctioning, and to prevent hypoxemia the
client should be pre-oxyginated with a manual resusotator bag set at
100% oxygen)
A nurse is assessing a client immedietaly after the provider removes the clients
endotracheal tube. Which of the following findings should the nurse report to the
provider?
, 2021
a. Stridor
Alternating periods of hyperventilation and apnea is Cheyne-stokes breathing.
A nurse understands that there are three ways to decrease ventilator-assisted
pneumonia called a “ventilator bundle”. Which of the following three nursing
actions are included in the clients care bundle?
a. Hand hygiene, oral care, and HOB elevation
A nurse is caring for a client who has respiratory failure, is intubated, and is
mechanically ventilated. The client pulls out the edotrachial tube. Which of the
following is the priority action?
a. Ensure the airway is open
A nurse is assessing a clients wife how to take a blood pressure. Which of the
following actions by the wife indicates a need for further instructions?
a. Place the clients arm above the level of the heart
A nurse is monitoring a post-operative client who is unable to respond to questions.
Which of the following behviors should the nurse recognize as an indicator of
pain? (select all)
a. Resltlessness
b. Grimacing
c. Clenching
A nurse is assisting with the discharge plan of a client who has a permanent
tracheostomy. The nurse should verify the availability of which of the following
equipment? (select all)
a. Oxygen
b. Suction machine
c. Replacement canula
A nurse is giving shift report using SBAR to the oncoming nurse on a client who
has traumatic brain injury. When reporting information about the client, which of
the following are included in the situation of SBAR?
a. History of the injury
, 2021
SBAR examples:
1. Gaslow coma scales falls under assessment
2. Intercranial pressure readings falls under assessment
3. Medication that is needed falls under recommendations
A nurse is monitoring the cardiac output of a client who has left sided heart failure
using pulse pressure analysis. Which of the following findings can compromise the
reading?
a. The client is experiencing premature atrial contractions.
A nurse in the ICU is providing teaching for a client proior to the removal of an
endotracheal tube. Which of the following instructions should the nurse include in
the teaching?
a. Avoid speaking for long periods
A nurse is caring for a client who has severe head injuries and is declared brain
dead. The transplant coordinator has spoken with the clients family about organ
donation. The clients spouce states she is confused and does not know what she
should do. Which of the following responses by the nurse is appropriate?
a. What do you think your spouse would have wants?
A client is performing nasotrachial suctioning for a client who has COPD and an
artificial airway. Which of the following actions should the nurse take?
a. Preoxygenate the clients with 100% oxygen for up to 3 min.
A charge nurse has access to the faciliteies electronic records. It is appropriate for
the charge nurse to share her personal password with whom?
a. No one
A nurse is assessing a group of clients for hospice services. The nurse should
recommend hospice care for which of the following clients?
