NUR 370 (23) Actual Questions and Correct Answers
Q1
symptom suggests complete airway obstruction by a foreign body?
Answer: Gagging Coughing Inability to speak Rapid respirations
Q2
the RN's priority?
Answer: The surgical site dressing has a scant amount of bright red blood. The client is sleeping
but easily arouses when touched. The client's respirations are 6 to 8 breaths per minute. The
client's bloodpressure is 100/68 mm Hg
Q3
requires the nurse's immediate attention?
Answer: "I have bad pain in my lower leg" "I just can't 'catch my breath" "I have to use the bedpan
to pee at least every hour." "The pain medication is not working today."
Q4
There has been a train
Answer: D. Client who is 25 years old with an open chest wall
Q5
derailment and four
Answer: wound
Q6
people are injured. Which
Answer: Because of open-chest wall wound = at risk for
Q7
patient should the RN see
Answer: pneumothorax or hemothorax = life-threatening
,Q8
B.Client who is 80 years
Answer: Client who is 80 years
Q9
C.Client who is 10 years
Answer: Client who is 10 years
Q10
D.Client who is 25 years
Answer: Client who is 25 years
Q11
The client just returned to the nursing unit following surgery. Which observation by the RN requires the
most immediate intervention?A. The client is sleepyB. The client coughed up blood-tinged sputumC
Oxygen saturation level is 82%D. Jackson-Pratt wound drain is half full
Answer: C. Oxygen saturation level is 82%
Q12
At 0730 hours, the oncoming RN is planning care for four clients. Which client should the RN plan to
assess first?A.The 23-year-old client with cystic fibrosis who has pulmonary function tests scheduled in
ten minutesB.The 35-year-old clientadmitted the previous day with bacterial pneumonia and now has a
temperature of 39.4oC C.The 46-year-old client who had a chest tube removed an hour ago and now
has dyspneaD.The 77-year-old client with tuberculosis who has four anti-tubercular medications due at
08:00 hours
Answer: C. The 46-year-old client who had a chest tube removed an hour ago and now has
dyspnea
Q13
What is the purpose of the ABCDE approach?
Answer: To provide life-saving treatmentTo break down complex clinical situations into more
manageable
partsTo serve as an assessment and treatment algorithm To establish common situational
awareness
among all treatment providersTo buy time to establish a final diagnosis and treatment (identifies
priority needs and guides nursing practice)Can be initiated without any equipment and more
advanced
interventions can be applied on arrival of emergency medical services, in a clinic, or at the
hospital.Assessments should be repeated until the patient isstable, regularly, and/or at any sign of
deterioration
, Q14
What are strategies for prioritizing care?
Answer: Central focus on prioritization of Client care:-Priority 1 - life threatening illness (ex:
airway obstruction,
myocardial infarction)-Priority 2 - safety (ex: of patient and family, nurse and health
professionals)-Priority 3 - client priorities (ex: pain, nausea)-Priority 4 - nurse priorities (ex: a
nursing
intervention appropriate for the situation)
Q15
What are normal/expected airwayfindings?
Answer: Patient responds in a normalvoice Regular and visible respirations
Q16
What are abnormal/unexpected airway findings?
Answer: Partial obstruction = voice changes, noisy breathing, and increased breathing
effortComplete
obstruction = there is no respiration despite great effort, unconscious
Q17
What are possible airway interventions?
Answer: List them
Q18
What arenormal/expected breathing findings?
Answer: Respiratory rate appropriate for age, normal O2SatSymmetrical and visible movements of
the thoracic
Percussed unilateral dullness or resonance
Q19
What are abnormal/unexpected breathing findings?
Answer: CyanosisDistended neck veins Lateralization of the tracheaTension pneumothorax (air
trapped in
pleural space)Bronchospasms
Q20
What are possible breathing interventions?
Answer: List them
Q1
symptom suggests complete airway obstruction by a foreign body?
Answer: Gagging Coughing Inability to speak Rapid respirations
Q2
the RN's priority?
Answer: The surgical site dressing has a scant amount of bright red blood. The client is sleeping
but easily arouses when touched. The client's respirations are 6 to 8 breaths per minute. The
client's bloodpressure is 100/68 mm Hg
Q3
requires the nurse's immediate attention?
Answer: "I have bad pain in my lower leg" "I just can't 'catch my breath" "I have to use the bedpan
to pee at least every hour." "The pain medication is not working today."
Q4
There has been a train
Answer: D. Client who is 25 years old with an open chest wall
Q5
derailment and four
Answer: wound
Q6
people are injured. Which
Answer: Because of open-chest wall wound = at risk for
Q7
patient should the RN see
Answer: pneumothorax or hemothorax = life-threatening
,Q8
B.Client who is 80 years
Answer: Client who is 80 years
Q9
C.Client who is 10 years
Answer: Client who is 10 years
Q10
D.Client who is 25 years
Answer: Client who is 25 years
Q11
The client just returned to the nursing unit following surgery. Which observation by the RN requires the
most immediate intervention?A. The client is sleepyB. The client coughed up blood-tinged sputumC
Oxygen saturation level is 82%D. Jackson-Pratt wound drain is half full
Answer: C. Oxygen saturation level is 82%
Q12
At 0730 hours, the oncoming RN is planning care for four clients. Which client should the RN plan to
assess first?A.The 23-year-old client with cystic fibrosis who has pulmonary function tests scheduled in
ten minutesB.The 35-year-old clientadmitted the previous day with bacterial pneumonia and now has a
temperature of 39.4oC C.The 46-year-old client who had a chest tube removed an hour ago and now
has dyspneaD.The 77-year-old client with tuberculosis who has four anti-tubercular medications due at
08:00 hours
Answer: C. The 46-year-old client who had a chest tube removed an hour ago and now has
dyspnea
Q13
What is the purpose of the ABCDE approach?
Answer: To provide life-saving treatmentTo break down complex clinical situations into more
manageable
partsTo serve as an assessment and treatment algorithm To establish common situational
awareness
among all treatment providersTo buy time to establish a final diagnosis and treatment (identifies
priority needs and guides nursing practice)Can be initiated without any equipment and more
advanced
interventions can be applied on arrival of emergency medical services, in a clinic, or at the
hospital.Assessments should be repeated until the patient isstable, regularly, and/or at any sign of
deterioration
, Q14
What are strategies for prioritizing care?
Answer: Central focus on prioritization of Client care:-Priority 1 - life threatening illness (ex:
airway obstruction,
myocardial infarction)-Priority 2 - safety (ex: of patient and family, nurse and health
professionals)-Priority 3 - client priorities (ex: pain, nausea)-Priority 4 - nurse priorities (ex: a
nursing
intervention appropriate for the situation)
Q15
What are normal/expected airwayfindings?
Answer: Patient responds in a normalvoice Regular and visible respirations
Q16
What are abnormal/unexpected airway findings?
Answer: Partial obstruction = voice changes, noisy breathing, and increased breathing
effortComplete
obstruction = there is no respiration despite great effort, unconscious
Q17
What are possible airway interventions?
Answer: List them
Q18
What arenormal/expected breathing findings?
Answer: Respiratory rate appropriate for age, normal O2SatSymmetrical and visible movements of
the thoracic
Percussed unilateral dullness or resonance
Q19
What are abnormal/unexpected breathing findings?
Answer: CyanosisDistended neck veins Lateralization of the tracheaTension pneumothorax (air
trapped in
pleural space)Bronchospasms
Q20
What are possible breathing interventions?
Answer: List them
