NUR 210 Exam 2024 A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.40, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis D. Metabolic alkalosis - ANSWER B. Respiratory alkalosis (Causes: hyperventilation, fever and respiratory infections)
A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the clients room? (select all that apply)
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing - ANSWER A. Oxygen
B. Sterile water
C. enclosed hemostat clamps
E. Occlusive dressing A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first?
A. Obtain a chest x-ray
B. Apply sterile gauze to the insertion site
C. Place tape around the insertion site
D. Assess respiratory status - ANSWER B. Apply sterile gauze to the insertion site (ABC, allows air to escape and decreases risk of tension pneumothorax)
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (select all that apply)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and
expiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level - ANSWER B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and
expiration
A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do?
A. Lie on his left side
B. Use the incentive spirometer
C. Cough at regular intervals D. Perform the Valsalva maneuver - ANSWER D. Perform the Valsalva maneuver (tell client to take a deep breath, exhale and bear down)
A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (select all that apply)
A. Encourage the client to cough every 2 hours
B. Check for continuous bubbling in the suction chamber
C. Strip the drainage tubing every 4 hours
D. Clamp the tube once a day
E. Obtain a chest x-ray - ANSWER A. Encourage the client to cough every 2 hours
B. Check for continuous bubbling in the suction chamber
E. Obtain a chest x-ray
A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and
understanding of PSV?
A. "It keeps the alveoli open and prevents atelectasis"
B. "It allows preset pressure delivered during spontaneous ventilation"
C. "It guarantees minimal minute ventilator"
D. "It delivers a preset ventilatory rate and tidal volume to the client" - ANSWER B. "It allows preset pressure delivered during spontaneous ventilation" (decreases work of breathing) A nurse is caring for a client who is experiencing respiratory distress. Which of the
following early manifestations of hypoxemia should the nurse recognize? (select all that apply)
A. Confusion
B. Pale skin
C. Bradycardia
D. Hypotension
E. Elevated blood pressure - ANSWER B. Pale skin
E. Elevated blood pressure
A nurse is orienting a newly licensed nurse on preforming routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?
A. Apply a vest restraint if self-extubation is attempted
B. Monitor ventilator settings every 8 hours
C. Document tube placement in centimeters at the angle of jaw
D. Assess breath sounds every 1 to 2 hours - ANSWER D. Assess breath sounds every 1 to 2 hours
A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask - ANSWER B. Venturi mask
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis D. Metabolic alkalosis - ANSWER B. Respiratory alkalosis (Causes: hyperventilation, fever and respiratory infections)
A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the clients room? (select all that apply)
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing - ANSWER A. Oxygen
B. Sterile water
C. enclosed hemostat clamps
E. Occlusive dressing A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first?
A. Obtain a chest x-ray
B. Apply sterile gauze to the insertion site
C. Place tape around the insertion site
D. Assess respiratory status - ANSWER B. Apply sterile gauze to the insertion site (ABC, allows air to escape and decreases risk of tension pneumothorax)
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (select all that apply)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and
expiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level - ANSWER B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration and
expiration
A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do?
A. Lie on his left side
B. Use the incentive spirometer
C. Cough at regular intervals D. Perform the Valsalva maneuver - ANSWER D. Perform the Valsalva maneuver (tell client to take a deep breath, exhale and bear down)
A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (select all that apply)
A. Encourage the client to cough every 2 hours
B. Check for continuous bubbling in the suction chamber
C. Strip the drainage tubing every 4 hours
D. Clamp the tube once a day
E. Obtain a chest x-ray - ANSWER A. Encourage the client to cough every 2 hours
B. Check for continuous bubbling in the suction chamber
E. Obtain a chest x-ray
A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates and
understanding of PSV?
A. "It keeps the alveoli open and prevents atelectasis"
B. "It allows preset pressure delivered during spontaneous ventilation"
C. "It guarantees minimal minute ventilator"
D. "It delivers a preset ventilatory rate and tidal volume to the client" - ANSWER B. "It allows preset pressure delivered during spontaneous ventilation" (decreases work of breathing) A nurse is caring for a client who is experiencing respiratory distress. Which of the
following early manifestations of hypoxemia should the nurse recognize? (select all that apply)
A. Confusion
B. Pale skin
C. Bradycardia
D. Hypotension
E. Elevated blood pressure - ANSWER B. Pale skin
E. Elevated blood pressure
A nurse is orienting a newly licensed nurse on preforming routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?
A. Apply a vest restraint if self-extubation is attempted
B. Monitor ventilator settings every 8 hours
C. Document tube placement in centimeters at the angle of jaw
D. Assess breath sounds every 1 to 2 hours - ANSWER D. Assess breath sounds every 1 to 2 hours
A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask - ANSWER B. Venturi mask
