RNSG 1517 Exam 2 Questions and Correct
Answers (Verified Answers) Plus Rationale
2027 Q&A| Instant Download Pdf
1. A nurse is assessing a client who reports shortness of breath.
Which assessment finding requires the nurse's immediate
attention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 89%
C. Temperature of 37.2°C (99°F)
D. Pulse rate of 82/min
Answer: B. Oxygen saturation of 89%
Rationale: An oxygen saturation of 89% indicates hypoxemia and
requires prompt assessment and intervention. The nurse should assess
airway and breathing, position the client appropriately, and provide
oxygen according to the prescribed plan. The other findings are within
expected ranges for most adults.
, 2. Which position is most appropriate for a client experiencing
difficulty breathing?
A. Supine
B. Trendelenburg
C. High-Fowler's
D. Prone
Answer: C. High-Fowler's
Rationale: High-Fowler's position promotes maximum lung expansion
by allowing the diaphragm to move downward and reducing pressure
from abdominal organs. It is commonly used for clients experiencing
dyspnea. Supine and Trendelenburg positions can interfere with
optimal ventilation.
3. A nurse is caring for a client with a productive cough. Which
intervention best promotes secretion clearance?
A. Restrict oral fluids
B. Encourage adequate hydration if not contraindicated
C. Keep the client flat in bed
D. Discourage coughing
Answer: B. Encourage adequate hydration if not contraindicated
,Rationale: Adequate hydration helps thin respiratory secretions,
making them easier to expectorate. Positioning, coughing exercises,
and mobility may also facilitate secretion clearance. Fluid restriction
can make secretions thicker unless restriction is specifically prescribed.
4. Which assessment finding is most consistent with hypoxia?
A. Restlessness and confusion
B. Warm, dry skin
C. Bradycardia in every case
D. Increased appetite
Answer: A. Restlessness and confusion
Rationale: Early manifestations of inadequate oxygenation can
include restlessness, anxiety, difficulty concentrating, and confusion.
Cyanosis is generally a later and less reliable sign. The nurse should
promptly assess oxygenation when these changes occur.
5. A client is receiving oxygen through a nasal cannula. Which
nursing action is appropriate?
A. Apply petroleum jelly around the nares
B. Ensure the tubing is positioned safely
C. Set the oxygen flow rate independently without an order
D. Remove oxygen during episodes of dyspnea
, Answer: B. Ensure the tubing is positioned safely
Rationale: The nurse should ensure that oxygen tubing is correctly
positioned and does not create a fall or pressure injury risk.
Petroleum-based products should not be used around oxygen
equipment because they can increase fire risk. Oxygen flow should be
administered according to the prescription or applicable protocol.
6. Which intervention is most effective for preventing postoperative
atelectasis?
A. Maintaining prolonged bed rest
B. Encouraging incentive spirometry
C. Limiting coughing
D. Restricting fluid intake
Answer: B. Encouraging incentive spirometry
Rationale: Incentive spirometry encourages deep inspiration and helps
expand collapsed or poorly ventilated alveoli. Early ambulation,
repositioning, coughing, and deep-breathing exercises also help
reduce the risk of atelectasis.
7. A nurse teaches a client how to use an incentive spirometer.
Which instruction is correct?
Answers (Verified Answers) Plus Rationale
2027 Q&A| Instant Download Pdf
1. A nurse is assessing a client who reports shortness of breath.
Which assessment finding requires the nurse's immediate
attention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 89%
C. Temperature of 37.2°C (99°F)
D. Pulse rate of 82/min
Answer: B. Oxygen saturation of 89%
Rationale: An oxygen saturation of 89% indicates hypoxemia and
requires prompt assessment and intervention. The nurse should assess
airway and breathing, position the client appropriately, and provide
oxygen according to the prescribed plan. The other findings are within
expected ranges for most adults.
, 2. Which position is most appropriate for a client experiencing
difficulty breathing?
A. Supine
B. Trendelenburg
C. High-Fowler's
D. Prone
Answer: C. High-Fowler's
Rationale: High-Fowler's position promotes maximum lung expansion
by allowing the diaphragm to move downward and reducing pressure
from abdominal organs. It is commonly used for clients experiencing
dyspnea. Supine and Trendelenburg positions can interfere with
optimal ventilation.
3. A nurse is caring for a client with a productive cough. Which
intervention best promotes secretion clearance?
A. Restrict oral fluids
B. Encourage adequate hydration if not contraindicated
C. Keep the client flat in bed
D. Discourage coughing
Answer: B. Encourage adequate hydration if not contraindicated
,Rationale: Adequate hydration helps thin respiratory secretions,
making them easier to expectorate. Positioning, coughing exercises,
and mobility may also facilitate secretion clearance. Fluid restriction
can make secretions thicker unless restriction is specifically prescribed.
4. Which assessment finding is most consistent with hypoxia?
A. Restlessness and confusion
B. Warm, dry skin
C. Bradycardia in every case
D. Increased appetite
Answer: A. Restlessness and confusion
Rationale: Early manifestations of inadequate oxygenation can
include restlessness, anxiety, difficulty concentrating, and confusion.
Cyanosis is generally a later and less reliable sign. The nurse should
promptly assess oxygenation when these changes occur.
5. A client is receiving oxygen through a nasal cannula. Which
nursing action is appropriate?
A. Apply petroleum jelly around the nares
B. Ensure the tubing is positioned safely
C. Set the oxygen flow rate independently without an order
D. Remove oxygen during episodes of dyspnea
, Answer: B. Ensure the tubing is positioned safely
Rationale: The nurse should ensure that oxygen tubing is correctly
positioned and does not create a fall or pressure injury risk.
Petroleum-based products should not be used around oxygen
equipment because they can increase fire risk. Oxygen flow should be
administered according to the prescription or applicable protocol.
6. Which intervention is most effective for preventing postoperative
atelectasis?
A. Maintaining prolonged bed rest
B. Encouraging incentive spirometry
C. Limiting coughing
D. Restricting fluid intake
Answer: B. Encouraging incentive spirometry
Rationale: Incentive spirometry encourages deep inspiration and helps
expand collapsed or poorly ventilated alveoli. Early ambulation,
repositioning, coughing, and deep-breathing exercises also help
reduce the risk of atelectasis.
7. A nurse teaches a client how to use an incentive spirometer.
Which instruction is correct?
