, 1- A charge nurse receives notification of the admission of a client who is coughing frequently and
whose sputum is pink, frothy, and copious. The client has history of night sweats, anorexia, and
weight loss. Which of the following actions should the nurse take? (SATA)
-Assign the client to a private room with negative-pressure airflow
-Wear an N95 respirator when entering the client’s room.
2- A nurse is assisting a provider with a comprehensive physical examination of a client. When the
provider uses transillumination, the nurse should explain to the client that this technique help
evaluate which of the following structures?
-Maxillary sinuses
3- A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How
should the nurse assist the client with smoking cessation?
-Discuss ways the client can reduce the number of cigarettes smoked per day.
4- A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD)
and is malnourished. Which of the following recommendations to promote nutritional intake
shouldthe nurse include in the plan?
-Eat high-calorie food first.
Rational: client who has COPD experience early satiety. Client should eat calorie-dense food first.
5- A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should
identify that which of the following findings is an adverse effect of this medication?
-Tinnitus.
Rational: An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.
6- A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of
the following findings is a manifestation of a pulmonary embolism?
-Stabbing chest pain
Rational: sudden chest pain that is sharp and stabbing is a manifestation of pulmonary
embolism. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood),
tachypnea, tachycardia, diaphoresis, and feeling of impending doom.
,7- A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and
a high-pitched inspiratory sound (stridor). The nurse should identify theses findings as
manifestations of which of the following complications?
-Respiratory obstruction
8- A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the
following laboratory values should the nurse expect?
-ph 7.49,HCO3-32mEq/L, PaCO2 40mmHg
Rational: Metabolic alkalosis: pH and bicarbonate values are greater than the expectedreferences
range, and the PaCO2 is within the expected reference range.
9- A nurse is providing teaching to a client who has a chronic cough and is scheduled for a
bronchoscopy. Which of the following client statements indicates an understanding of the
teaching?
-“A tissue sample might be obtained during the procedure”
10- A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse
take? (SATA)
-Explain that the client will receive sedation and will not remember the procedure.
-Verify that the client understands the purpose and nature of the procedure.
11- A nurse is preparing a client for discharge following a bronchoscopy. Which of the
followingassessment is the nurse’s monitoring priority?
-Confirming the gag reflex
Rational: The greater risk to the client’s safety is aspiration resulting from a depressed gag reflex.
12- A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2
chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall.
When a family member asks why the client has 2 chest tubes, which of the following responses
should the nurse make?
-“The lower tube will drain blood, and the higher tube will remove air.”
13- A nurse is providing teaching to a client who will undergo a total laryngectomy. Which of the
following statements indicate that the client understands the impact of the surgery?
, - “I Bunderstands Bthat BI Bwill Bhave Ba Bpermanent Btracheostomy Bafter Bthe Bsurgery.”
Rational: BWith Ba Bpartial Blaryngectomy, Bthe Btracheostomy Bis Btemporary. BWith Bthe Btotal Blaryngectomy
BtheB
tracheostomy Bwill Bbe Bpermanent.
14- A Bnurse Bis Bproviding Bdischarge Binstructions Bto Ba Bclient Bwho Bhas Ba Bnew Blaryngectomy. BThe
BnurseB
tells Bthe Bclient Bto Bbe Bcareful Bwhile Bbathing Bto Bprevent Bwhich Bof Bthe Bfollowing
Bcomplications?
-Aspiration Bof Bwater.
Rational: BThis Bis Ba Bclient Bwith Ba Btracheostomy, Bso Bhe Bwill Bneed Bto Buse Ba Bshower Bshield Bover
BthestomaB
when Bbathing Bor Bshowering Bto Bkeep Bwater Bout Bof Bthe Bairway.
15- A Bnurse Bis Bcaring Bfor Ba Bclient Bwho Bis Bextremely Banxious Band Bis Bhyperventilating. BThe
Bclient’s BABG Bresults Bare BpH B7.50, BPaCO2 B27 BmmHg, Band BHCO3-25 BmEq/L. BThe Bnurse
Bshould Bidentify Bthat Btheclient Bhas Bwhich Bof Bthe Bfollowing Bacid-base Bimbalances?
-Respiratory Balkalosis.
16- A Bnurse Bis Bplanning Bpostoperative Beducation Bfor Ba Bclient Bwho Bwill Bundergo Ba Bradical
Bneck Bdissection Bfor Bcancer Bof Bthe Blarynx. BThe Bnurse Bshould Binclude Bwhich Bof Bthe
Bfollowing Btopics?B(SATA)
-NPO Bstatus
-Alternative Bmethods Bof Bcommunication
- Changes Bin Bbody Bimage
-Swallowing Bexercises.
17- A Bnurse Bin Ba Bclinic Bis Bproviding Bteaching Bfor Ba Bclient Bwho Bis Bscheduled Bto Bhave Ba
BtuberculinBskintest. BWhich Bof Bthe Bfollowing Bpieces Bof Binformation Bshould Bthe Bnurse
Binclude?
- B“You Bmust Breturn Bto Bthe Bclinic Bto Bhave Bthe Btest Bread Bin B2 Bor B3 Bdays.”
18- A Bnurse Bis Bproviding Bdischarge Bteaching Bto Ba Bclient Bwho Bis Bpostoperative Bfollowing Ba
Brhinoplasty/B Which Bof Bthe Bfollowing Binstructions Bshould Bthe Bnurse Binclude?
“Lie Bon Byour Bback Bwith Byour Bhead Belevated B30º Bwhen Bresting.”
19- ABnurse Bis Bpreparing Bto Bassist Bprovider Bwith Ban Barterial Bblood Bwithdrawal Bfrom Ba
Bclient’sradialBartery Bfor BABG Bmeasurements. BWhich Bof Bthe Bfollowing Bactions Bthe Bnurse
Bplan Bto Btake?
whose sputum is pink, frothy, and copious. The client has history of night sweats, anorexia, and
weight loss. Which of the following actions should the nurse take? (SATA)
-Assign the client to a private room with negative-pressure airflow
-Wear an N95 respirator when entering the client’s room.
2- A nurse is assisting a provider with a comprehensive physical examination of a client. When the
provider uses transillumination, the nurse should explain to the client that this technique help
evaluate which of the following structures?
-Maxillary sinuses
3- A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How
should the nurse assist the client with smoking cessation?
-Discuss ways the client can reduce the number of cigarettes smoked per day.
4- A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD)
and is malnourished. Which of the following recommendations to promote nutritional intake
shouldthe nurse include in the plan?
-Eat high-calorie food first.
Rational: client who has COPD experience early satiety. Client should eat calorie-dense food first.
5- A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should
identify that which of the following findings is an adverse effect of this medication?
-Tinnitus.
Rational: An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.
6- A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of
the following findings is a manifestation of a pulmonary embolism?
-Stabbing chest pain
Rational: sudden chest pain that is sharp and stabbing is a manifestation of pulmonary
embolism. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood),
tachypnea, tachycardia, diaphoresis, and feeling of impending doom.
,7- A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and
a high-pitched inspiratory sound (stridor). The nurse should identify theses findings as
manifestations of which of the following complications?
-Respiratory obstruction
8- A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the
following laboratory values should the nurse expect?
-ph 7.49,HCO3-32mEq/L, PaCO2 40mmHg
Rational: Metabolic alkalosis: pH and bicarbonate values are greater than the expectedreferences
range, and the PaCO2 is within the expected reference range.
9- A nurse is providing teaching to a client who has a chronic cough and is scheduled for a
bronchoscopy. Which of the following client statements indicates an understanding of the
teaching?
-“A tissue sample might be obtained during the procedure”
10- A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse
take? (SATA)
-Explain that the client will receive sedation and will not remember the procedure.
-Verify that the client understands the purpose and nature of the procedure.
11- A nurse is preparing a client for discharge following a bronchoscopy. Which of the
followingassessment is the nurse’s monitoring priority?
-Confirming the gag reflex
Rational: The greater risk to the client’s safety is aspiration resulting from a depressed gag reflex.
12- A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2
chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall.
When a family member asks why the client has 2 chest tubes, which of the following responses
should the nurse make?
-“The lower tube will drain blood, and the higher tube will remove air.”
13- A nurse is providing teaching to a client who will undergo a total laryngectomy. Which of the
following statements indicate that the client understands the impact of the surgery?
, - “I Bunderstands Bthat BI Bwill Bhave Ba Bpermanent Btracheostomy Bafter Bthe Bsurgery.”
Rational: BWith Ba Bpartial Blaryngectomy, Bthe Btracheostomy Bis Btemporary. BWith Bthe Btotal Blaryngectomy
BtheB
tracheostomy Bwill Bbe Bpermanent.
14- A Bnurse Bis Bproviding Bdischarge Binstructions Bto Ba Bclient Bwho Bhas Ba Bnew Blaryngectomy. BThe
BnurseB
tells Bthe Bclient Bto Bbe Bcareful Bwhile Bbathing Bto Bprevent Bwhich Bof Bthe Bfollowing
Bcomplications?
-Aspiration Bof Bwater.
Rational: BThis Bis Ba Bclient Bwith Ba Btracheostomy, Bso Bhe Bwill Bneed Bto Buse Ba Bshower Bshield Bover
BthestomaB
when Bbathing Bor Bshowering Bto Bkeep Bwater Bout Bof Bthe Bairway.
15- A Bnurse Bis Bcaring Bfor Ba Bclient Bwho Bis Bextremely Banxious Band Bis Bhyperventilating. BThe
Bclient’s BABG Bresults Bare BpH B7.50, BPaCO2 B27 BmmHg, Band BHCO3-25 BmEq/L. BThe Bnurse
Bshould Bidentify Bthat Btheclient Bhas Bwhich Bof Bthe Bfollowing Bacid-base Bimbalances?
-Respiratory Balkalosis.
16- A Bnurse Bis Bplanning Bpostoperative Beducation Bfor Ba Bclient Bwho Bwill Bundergo Ba Bradical
Bneck Bdissection Bfor Bcancer Bof Bthe Blarynx. BThe Bnurse Bshould Binclude Bwhich Bof Bthe
Bfollowing Btopics?B(SATA)
-NPO Bstatus
-Alternative Bmethods Bof Bcommunication
- Changes Bin Bbody Bimage
-Swallowing Bexercises.
17- A Bnurse Bin Ba Bclinic Bis Bproviding Bteaching Bfor Ba Bclient Bwho Bis Bscheduled Bto Bhave Ba
BtuberculinBskintest. BWhich Bof Bthe Bfollowing Bpieces Bof Binformation Bshould Bthe Bnurse
Binclude?
- B“You Bmust Breturn Bto Bthe Bclinic Bto Bhave Bthe Btest Bread Bin B2 Bor B3 Bdays.”
18- A Bnurse Bis Bproviding Bdischarge Bteaching Bto Ba Bclient Bwho Bis Bpostoperative Bfollowing Ba
Brhinoplasty/B Which Bof Bthe Bfollowing Binstructions Bshould Bthe Bnurse Binclude?
“Lie Bon Byour Bback Bwith Byour Bhead Belevated B30º Bwhen Bresting.”
19- ABnurse Bis Bpreparing Bto Bassist Bprovider Bwith Ban Barterial Bblood Bwithdrawal Bfrom Ba
Bclient’sradialBartery Bfor BABG Bmeasurements. BWhich Bof Bthe Bfollowing Bactions Bthe Bnurse
Bplan Bto Btake?
