Nursing Exam 3 Practice Questions with Correct Answers (2025 Version) Get an A.

Nursing Exam 3 Practice Questions with Correct Answers (2025 Version) Get an A. The nurse is preparing to send a client to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the client's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the client. What is the nurse's best action to the physician's request? A) Inform the physician that it is his or her responsibility to obtain the signature. B) Obtain the signature and ask another nurse to cosign the signature. C) Inform the physician that the nurse manager will need to obtain the signature. D) Call the house officer to obtain the signature. A Upon assessment, a client reports that he drinks five to six bottles of beer every evening after work. Based upon this information, the nurse is aware that the client may require which of the following? A) Larger doses of anesthetic agents and larger doses of postoperative analgesics B) Larger doses of anesthetic agents and lower doses of postoperative analgesics C) Lower doses of anesthetic agents and lower doses of postoperative analgesics D) Lower doses of anesthetic agents and larger doses of postoperative analgesics A The telemetry unit nurse is reviewing laboratory results for a client who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the client has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia. The nurse informs the physician of this laboratory result because the nurse recognizes hyperkalemia increases the client's operative risk for which of the following? A) Cardiac problems B) Infection C) Bleeding and anemia D) Fluid imbalances A The nurse is providing education to a client regarding pain control after surgery. What time does the nurse inform the client is the best time to request pain medication? A) Before the pain becomes severe B) When the client experiences a pain rating of "10" on a 1-to-10 pain scale C) When there is no pain, but it is time for the medication to be administered D) After the pain becomes severe and relaxation techniques have failed A A client returning to the floor after orthopedic surgery is complaining of nausea. The nurse is aware that an appropriate intervention is to do which of the following? A) Avoid strong smelling foods. B) Provide clear liquids with a straw. C) Avoid oral hygiene until the nausea subsides. D) Hold all medications. A In order to prevent the possibility of venous stasis, a nurse is teaching a surgical client how to perform leg exercises. Which of the client's following statements indicates a sound understanding of leg exercises? A) "I'll practice these now and try to start them as soon as I can after my surgery." B) "I'll try to do these lying on my stomach so that I can bend my knees more fully." C) "I'll make sure to do these, as long as my doctor doesn't tell me to stay on bed rest after my operation." D) "I'm pretty sure my stomach muscles are strong enough to lift both of my legs off the bed at the same time." A A female client is scheduled for liposuction surgery to reduce her weight. Based on urgency, how is this surgery classified? A) Urgent B) Elective C) Emergency D) Emergent B A client scheduled for major surgery will receive general anesthesia. Why is inhalation anesthesia often used to provide the desired actions? A) Rapid excretion and reversal of effects B) Safe administration in the client's own room C) Involves only the respiratory system and skin D) Slow onset of action and maintains reflexes A A nurse is educating a client about regional anesthesia. Which of the following statements is accurate about this type of anesthesia? A) "You will be asleep and won't be aware of the procedure." B) "You will be asleep but may feel some pain during the procedure." C) "You will be awake but will not be aware of the procedure." D) "You will be awake and will not have sensation of the procedure." D A nurse has been asked to ensure informed consent for a surgical procedure. What might be a role of the nurse? A) Securing informed consent from the client B) Signing the consent form as a witness C) Ensuring the client does not refuse treatment D) Refusing to participate based on legal guidelines B A client, scheduled for open-heart surgery, tells the nurse he does not want to be "saved" if he dies during surgery. What should the nurse do next? A) Discuss with and document the wishes of the client and family B) Administer the ordered oral and intravenous preoperative medications C) Notify the physician after completion of the surgical procedure D) Verbally report the client's wishes to the operating room supervisor A An operating room nurse is preparing for a surgical procedure on an infant. The nurse's perioperative care is based on what physiologic factor that puts infants at greater risk from surgery than adults? A) Increased vascular rigidity B) Diminished chest expansion C) Lower total blood volume D) Decreased peripheral circulation C After conducting a preoperative health assessment, the nurse documents that the client has physical assessments supporting the medical diagnosis of emphysema. Based on this finding, what postoperative interventions would be included on the plan of care? A) Perform sterile dressing changes each morning. B) Administer pain medications as needed. C) Conduct a head-to-toe assessment each shift. D) Monitor respirations and breath sounds. D A preoperative assessment finds a client to be 75 pounds overweight. The client is to have abdominal surgery. What nursing diagnosis would be appropriate based on the client's weight? A) Risk for Aspiration B) Risk for Imbalanced Body Temperature C) Risk for Infection D) Risk for Falls C Which of the following interventions is of major importance during preoperative education? A) Performing skills necessary for gastrointestinal preparation B) Encouraging the client to identify and verbalize fears C) Discussing the site and extent of the surgical incision D) Telling the client not to worry or be afraid of surgery B A nurse is reviewing results of preoperative screening tests and notes the client's potassium level is dangerously low. What should the nurse do next? A) Nothing; potassium levels have no influence on surgical outcome. B) Include the information in the postoperative end of shift report. C) Document the data and notify the physician who will do the surgery. D) Ask the client and family members why the potassium is low. C A nurse is educating a surgical client on postoperative p.r.n. pain control. Which of the following should be included? A) "We will bring you pain medications; you don't need to ask." B) "Even if you have pain, you may get addicted to the drugs." C) "You won't have much pain so just tough it out." D) "You need to ask for the medication before the pain becomes severe." D A nurse is educating a preoperative client on how to cough effectively. What can the nurse tell the client to do to facilitate coughing? A) "Hold a pillow or folded bath blanket over the incision." B) "Get up and walk before you try to cough." C) "It would be best if you do not cough until you feel better." D) "When you cough, cover your nose and mouth with a tissue." A A cleansing enema is ordered for a client who is scheduled to have colon surgery. What is the rationale for this procedure? A) Surgical clients routinely are given a cleansing enema. B) Cleansing enemas are given before surgery at the client's request. C) There will be less flatus and discomfort postoperatively. D) Peristalsis does not return for 24 to 48 hours after surgery. D A nurse working in a PACU is responsible for conducting assessments on immediate postoperative clients. What is the purpose of these assessments? A) To determine the length of time to recover from anesthesia B) To use intraoperative data as a basis for comparison C) To focus on cardiovascular data and findings D) To prevent complications from anesthesia and surgery D A nurse is providing ongoing postoperative care to a client who has had knee surgery. The nurse assesses the dressing and finds it saturated with blood. The client is restless and has a rapid pulse. What should the nurse do next? A) Document the data and apply a new dressing. B) Apply a pressure dressing and report findings. C) Reassure the family that this is a common problem. D) Make assessments every 15 minutes for four hours. B A postoperative home care client has developed thrombophlebitis in her right leg. What category of medications will probably be prescribed for this cardiovascular complication? A) Anticoagulants B) Antibiotics C) Antihistamines D) Antigens A A student is assessing a postoperative client who has developed pneumonia. The plan of care includes positioning the client in the Fowler's or semi-Fowler's position. What is the rationale for this position? A) It increases blood flow to the heart. B) The client will be more comfortable and have less pain. C) It facilitates nursing assessments of skin color and temperature. D) It promotes full aeration of the lungs. D A young woman has been in an automobile crash that resulted in an amputation of her left lower leg. She verbalizes grief and loss. What knowledge by the nurse is used to provide interventions to help the client cope? A) The client should be grateful to be alive. B) This is a normal, appropriate response. C) This is an abnormal, inappropriate response. D) Tissue healing will help the client adapt. B A nurse in an outpatient surgical center is teaching a client about what will be necessary for discharge to home. What information should the nurse include about transportation? A) The client is not allowed to drive a car home. B) If the client is not dizzy, driving a car is allowed. C) Only adults over the age of 25 may drive home. D) None; this is not necessary information. A Which of the following interventions are recommended guidelines for meeting client postoperative elimination needs? A) Assess abdominal distention, especially if bowel sounds are audible or are low pitched. B) Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. C) Encourage food and fluid intake when ordered, especially dairy products and low-fiber foods. D) Assess for bladder distention by Palpating below the symphysis pubis if the client has not voided within eight hours after surgery. B A nurse is assisting a postoperative client with deep-breathing exercises. Which of the following is an accurate step for this procedure? A) Place the client in prone position, with the neck and shoulders supported. B) Ask the client to place the hands over the stomach, so he or she can feel the chest rise as the lungs expand. C) Ask the client to exhale rapidly and completely, and inhale through the nose rapidly and completely. D) Ask the client to hold his or her breath for three to five seconds and mentally count "one, one thousand, two, one thousand" and so forth. D A client with abdominal incisions experiences excruciating pain when he tries to cough. What should the nurse do to reduce the client's discomfort when coughing? A) Administer prescribed pain medication just before coughing. B) Ask the client to drink plenty of water before coughing. C) Ask the client to lie in a lateral position when coughing. D) Administer prescribed pain medication 30 minutes before deliberately attempting to cough. D A physician has ordered a nurse to administer conscious sedation to a client. Which of the following is possible after administering conscious sedation to a client? A) Client can respond verbally despite physical immobility. B) Client can tolerate long therapeutic surgical procedures. C) Client is relaxed, emotionally comfortable, and conscious. D) Client's consciousness level can be monitored by equipment. C A nurse is taking care of a client during the immediate post-operative period. Which of the following duties performed during the immediate post-operative period is most important? A) Ensure the safe recovery of surgical clients. B) Monitor the client for complications. C) Prepare a room for the client's return. D) Assess the client's health constantly. B A nurse is caring for a client who is scheduled to undergo a breast biopsy. Which of the following major tasks does the nurse perform immediately during the pre-operative period? A) Obtain a signature on the consent form. B) Review the surgical checklist. C) Conduct a nursing assessment. D) Reduce the dosage of toxic drugs. C A nurse is assisting a physician during a cesarean section for a client. The client is administered epidural anesthesia. Which of the following is an advantage of epidural anesthesia? A) It counteracts the effects of conscious sedation. B) It decreases the risk of gastrointestinal complications. C) It prevents clients from remembering the initial recovery period. D) It acts on the central nervous system to produce loss of sensation. B Which of the following nursing interventions occurs in the postoperative phase of the surgical experience? A) Airway/oxygen therapy/pulse oximetry B) Teaching deep breathing exercises C) Reviewing the meaning of p.r.n. orders for pain medications D) Putting in IV lines and administering fluids A Which statement accurately represents a recommended guideline when providing postoperative care for the following clients? A) Force fluids for an adult client who has a urine output of less that 30 mL per hour. B) If client is febrile within 12 hours of surgery, notify the physician immediately. C) If the dressing was clean but now has a large amount of fresh blood, remove the dressing and reapply it. D) If vital signs are progressively increasing or decreasing from baseline, notify the physician of possible internal bleeding. D A diabetic client is undergoing surgery to amputate a gangrenous foot. This procedure would be considered which of the following categories of surgery based on purpose? A) Diagnostic B) Ablative C) Palliative D) Reconstructive B A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, she informs the group that there are six classes of nutrients, and three supply the body with energy. What are the three sources of energy? A) Carbohydrates, protein, and lipids B) Vitamins, minerals, and water C) Carbohydrates, protein, and water D) Lipids, vitamins, and minerals A In planning to meet the nutritional needs of a critically ill client in the intensive care unit, which factor will increase the client's basal metabolic rate? A) Infection B) Advanced age C) Prolonged fasting D) Long periods of sleep A A client is interested in losing 15 pounds, and she informs the nurse she is counting her calorie intake each day. The client has a goal of losing one pound a week until she reaches her goal. The client asks the nurse how many calories she should decrease daily to lose a pound a week. What is the nurse's best response? A) 500 calories/day B) 200 calories/day C) 300 calories/day D) 400 calories/day A The nurse caring for a client for several days has assessed that he has been eating poorly during his hospitalization. Which nursing measure should the nurse implement to assist the client in improving his nutritional intake? A) Encourage his daughter to prepare food at home and bring it to the client. B) Serve large meals and encourage the client to eat as much as possible. C) Provide distractions while the client is fed so that he will eat more. D) Provide bland meals. A Which of the following nutritional guidelines should a nurse provide to a client who is entering the second trimester of her pregnancy? A) "You'll need to eat more calories and to make sure you eat a balanced diet high in nutrients." B) "Try to eat your normal number of calories, but aim to eat a diet that's higher in fruits and vegetables." C) "The more food energy you consume, the greater the chances that you will have a healthy pregnancy." D) "Maintain your regular calorie intake, but take some supplements and emphasize organic foods." A The nurse is testing the blood glucose levels of a client with a history of diabetes. The nurse has performed hand hygiene, checked the order, informed the client and turned on the monitor. After removing a test strip from the vial, the nurse should do which of the following? A) Confirm that the strip and the meter share the same code. B) Massage the client's finger toward the selected puncture site. C) Cleanse the client's finger with alcohol. D) Pierce the client's skin with the lancet. A A client is discussing weight loss with a nurse. The patient says, "I will not eat for two weeks, then I will lose at least 10 pounds." What should the nurse tell the client? A) "What a good idea. Go ahead. That will jump start your weight loss!" B) "Many people find that to be an ideal way to lose weight quickly and easily." C) "That will increase your metabolic rate and help you lose weight." D) "That will decrease your metabolic rate and make weight loss more difficult." D Which client will have an increased metabolic rate and require nutritional interventions? A) A healthy young adult who works in an office B) A retired person living in a temperate climate C) A person with a serious infection and fever D) An older, sedentary adult with painful joints C A nurse is helping a client design a weight-loss diet. To lose one pound of fat (3,500 calories) per week, how many calories should be decreased each day? A) 100 B) 250 C) 500 D) 1,000 C A hospitalized client has been NPO with only intravenous fluid intake for a prolonged period. What assessments might indicate protein-calorie malnutrition? A) Fever, joint pain, dehydration B) Poor wound healing, apathy, edema C) Sleep disturbances, anger, increased output D) Weight gain, visual deficits, erythema of skin B How often would a nurse recommend a client eat or drink a source of vitamin C? A) Once a week B) Once a month C) Three times a week D) Every day D While reviewing an adult client's chart, a nurse notes average daily intake of fluids as 2,000 mL/day. What will the nurse do based on this information? A) Change the plan of care to include forcing fluids. B) Ask the client to drink more water during the day. C) Post a sign limiting fluids to 1,000 mL every 24 hours. D) Continue with care; this is a normal fluid intake. D A nurse has documented that a client has anorexia. What does this term mean? A) Eating more than daily requirements B) Lack of appetite C) Vitamin C deficiency D) Fluid deficit B A nurse is discussing infant care with a woman who just had a baby girl. What type of nutrition would the nurse recommend for the infant? A) Solid foods after the first month B) No solid foods until age 1 year C) Bottle feeding with cow's milk D) Breast-feeding or formula with iron D What information do anthropometric measurements provide in adults? A) Indirect measure of protein and fat stores B) Direct measure of degree of obesity C) Indication of degree of growth rate D) Reflection of social interaction with others A What independent nursing intervention can be implemented to stimulate appetite? A) Administer prescribed medications. B) Recommend dietary supplements. C) Encourage or provide oral care. D) Assess manifestations of malnutrition. C A nurse is feeding a client. Which of the following statements would help a person maintain dignity while being fed? A) "I am going to feed you your cereal first, and then your eggs." B) "I wish I had more time so I could feed you all of your meal." C) "I know you don't like me to feed you, but you need to eat." D) "What part of your dinner would you like to eat first?" D A client has been prescribed a clear liquid diet. What food or fluids will be served? A) Milk, frozen dessert, egg substitutes B) High-calorie, high-protein supplements C) Hot cereals, ice cream, chocolate milk D) Jell-O, carbonated beverages, apple juice D What is the route of administration for TPN? A) Oral B) Subcutaneous C) Intramuscular D) Intravenous D A nurse is caring for a client with a history of cardiac and vascular disease. Which of the following fats should the nurse allow in the client's diet for his condition? A) Unsaturated fats B) Trans fats C) Saturated fats D) Hydrogenated fats A We have an expert-written solution to this problem! A client visits a health care facility with complaints of loss of appetite following a prolonged illness. How should the nurse document the client's condition? A) Emaciation B) Cachexia C) Anorexia D) Nausea C A nurse is caring for a client with excessive abdominal fat. Which of the following is a risk associated with excessive abdominal fat about which the nurse should inform the client? A) Emaciation B) Cachexia C) Cardiovascular disease D) Anorexia C A nurse is caring for a young adult female client who has a folic acid defiency. When teaching the client about this condition, the nurse would include a discussion about the client's increased risk for which of the following? A) Neural tube deficits in the fetus B) Inadequate absorption of calcium and phosphorus C) Hemolysis of red blood cells D) Impaired neuromuscular functioning A To promote health of the fetus, the nurse should instruct the woman in the first trimester of pregnancy to do which of the following? A) Eliminate high-fiber foods B) Eat foods high in folic acid C) Consume saturated fats D) Consume milk products in the last trimester B A nurse researching a diet for a client with diabetes includes foods that supply energy to the body. Which of the following are classes of nutrients that supply this energy? Select all that apply. A) Vitamins B) Proteins C) Fats D) Minerals E) Carbohydrates B C E Which of the following factors increase BMR? Select all that apply. A) Growth B) Infections C) Fever D) Emotional tension E) Aging A B C D Which of the following are signs and symptoms of poor nutritional status? A) Flaky facial skin, facial edema, pale skin color B) Tongue is a deep red in color with surface papillae present. C) Firm, pink nailbeds D) Firm hair that is resistant to plucking A Which of the following laboratory results indicates the presence of malnutrition? A) Serum albumin 2.8 g/dL B) Hemoglobin (Hgb) 11.3 g/dL C) Creatinine 1.9 mg/dL D) Hematocrit (Hct) 56% A A nutritionist helps to plan a diet for a client with diabetes. Which of the following foods is a carbohydrate that should be included to help improve glucose tolerance? A) Milk B) Eggs C) Oatmeal D) Nuts C A nurse calculates the BMI of a client during a general survey as 26. Under which of the following categories would this client fall? A) Underweight B) Normal C) Overweight D) Obesity Class I C A nurse is caring for a client with complaints of chest pain. Which of the following test results would indicate whether the client is at risk for cardiac disease? A) Test results of levels of unsaturated fats B) Test results for dyslipidemia C) Test results of levels of balanced proteins D) Test results of levels of calories in each food intake B For which of the following clients should the nurse anticipate the need for a pureed diet? A) A man whose stroke has resulted in difficulty swallowing B) A woman who has required gallbladder surgery C) A man with dementia who is unable to follow instructions D) An obese woman after bariatric surgery A A nurse performing a nutritional assessment determines that the BMI of a 5'11" (1.8 meters) male client who weighs 81 kilograms is which of the following? A) 25.1 B) 18.5 C) 20.3 D) 28.6 A Most nutritionists recommend increasing fiber in the diet. In addition to other benefits, how does fiber affect cholesterol? A) Increases fecal excretion of cholesterol B) Decreases fecal excretion of cholesterol C) Facilitates intake and use of trans fat D) Raises blood cholesterol levels A The nurse prepares to administer an intermittent feeding to a client who has a nasogastric feeding tube. Arrange the following steps in the correct order 1. Verify correct tube placement. 2. Position client with head of bed elevated 30 to 45° degrees 3. Aspirate all gastric contents. 4. Flush tube with 30 mL water. 5.Verify that residual volume is less than 400 mL. 2 1 3 5 4 The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan? A) Provide six small meals daily. B) Provide three large meals daily. C) Encourage the client to eat immediately before breathing treatments. D) Encourage the client to alternate eating and using a nebulizer during meal time. A The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority-nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions." Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? A) Encouraging the client to consume two to three quarts of clear fluids daily B) Creating an environment that is likely to reduce anxiety C) Positioning the client supine D) Encouraging the client to decrease the number of cigarettes smoked daily A While the nurse is providing morning hygiene for a client who has a chest tube, the client has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first respond to this event? A) Submerge the end of the tube in sterile water. B) Clamp the tube near the end and also near the insertion point. C) Place the end of the tube on a sterile surface and seek help promptly. D) Clean the end of the tube with an alcohol swab and reconnect it to the drainage unit. A A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function? A) Chemoreceptors B) Stretch receptors C) Respiratory center D) Oxygen center C Which of the following diseases may result in decreased lung compliance? A) Emphysema B) Appendicitis C) Acne D) Chronic diarrhea A A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate? A) changes in the alveolar-capillary membrane and diffusion B) alterations in the structures of the ribs and diaphragm C) rapid decreases in atmospheric and intrapulmonic pressures D) lower-than-normal concentrations of environmental oxygen A In what age group would a nurse expect to assess the most rapid respiratory rate? A) Older adults B) Middle adults C) Adolescents D) Infants D A father of a preschool-age child tells the nurse that his child "has had a constant cold since going to daycare." How would the nurse respond? A) "Your child must have a health problem that needs medical care." B) "Children in daycare have more exposure to colds." C) "Are you washing your hands before you touch the child?" D) "Be sure and have your child wear a protective mask at school." B A woman 90 years of age has been in an automobile crash and sustained four fractured ribs on the left side of her thorax. Based on her age and the injury, she is at risk for what complication? A) Pneumonia B) Altered thought processes C) Urinary incontinence D) Viral influenza A Which individual is at greater risk for respiratory illnesses from environmental causes? A) A farmer on a large farm B) A factory worker in a large city C) A woman living in a small town D) A child living in a rural area B A nurse is beginning to conduct a health history for a client with respiratory problems. He notes that the client is having respiratory distress. What would the nurse do next? A) Continue with the health history, but more slowly. B) Ask questions of the family instead of the client. C) Conduct the interview later and let the client rest. D) Initiate interventions to help relieve the symptoms. D An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur? A) Inspiration and expiration B) Only on inspiration C) Only on expiration D) When coughing A A client is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate? A) Anxiety B) Nausea C) Pain D) Hypothermia A A nurse is caring for a toddler who is having an acute asthmatic attack with copious mucus and difficulty breathing. The child's skin is cyanotic, respirations are labored and rapid, and pulse is rapid. What nursing diagnosis would have priority for care of this child? A) Anxiety B) Ineffective Airway Clearance C) Excess Fluid Volume D) Disturbed Sensory Perception B What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home? A) "Although the test is uncomfortable, it is not painful." B) "You will be asked to forcefully exhale into a mouthpiece." C) "The test is used to determine how much air you inhale." D) "You will do this each morning while still lying in bed." B What does pulse oximetry measure? A) Cardiac output B) Peripheral blood flow C) Arterial oxygen saturation D) Venous oxygen saturation C Of all factors, what is the most important risk factor in pulmonary disease? A) Air pollution from vehicles B) Dangerous chemicals in the workplace C) Active and passive cigarette smoke D) Loss of the ozone layer of the atmosphere C A nurse is caring for a client who suddenly begins to have respiratory difficulty. In what position would the nurse place the client to facilitate respirations? A) Supine B) Prone C) High-Fowler's D) Dorsal recumbent C A nurse is educating a preoperative client on how to effectively deep breathe. Which of the following would be included? A) "Make each breath deep enough to move the bottom ribs." B) "Breathe through the mouth when you inhale and exhale." C) "Breathe in through the mouth and out through the nose." D) "Practice deep breathing at least once each week." A A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure? A) Using upper chest muscles more effectively B) Replacing the use of incentive spirometry C) Reducing the need for p.r.n. pain medications D) Prolonging expiration to reduce airway resistance D A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them? A) "It is inserted into the space between the lining of the lungs and the ribs." B) "I don't exactly know, but I will make sure the doctor comes to explain." C) "It is inserted directly into the lung itself, connecting to a lung airway." D) "It is inserted into the peritoneal space and drains into the lungs." A What prevents air from re-entering the pleural space when chest tubes are inserted? A) The location of the tube insertion B) The sutures that hold in the tube C) A closed water-seal drainage system D) Respiratory inspiration and expiration C A nurse is educating a client who has congested lungs how to keep secretions thin, and more easily coughed up and expectorated. What would be one self-care measure to teach? A) Limit oral intake of fluids to less than 500 mL per day. B) Increase oral intake of fluids to two to three quarts per day. C) Maintain bed rest for at least three days. D) Take warm baths every night for a week B What category of medications may be administered by nebulizer or metered-dose inhaler to open narrowed airways? A) Bronchoconstrictors B) Antihistamines C) Narcotics D) Bronchodilators D A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage? A) Filters need to be cleaned regularly to avoid unpleasant taste or smell. B) The chest tube should not be separated from the drainage system unless clamped. C) A nasal cannula should be used to administer oxygen when cleaning the opening. D) A secondary source of oxygen should be available in case of power failure. B A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? A) It can cause the nasal mucosa to dry in case of high flow. B) It can cause anxiety in clients who are claustrophobic. C) It can create a risk of suffocation. D) It can result in an inconsistent amount of oxygen. A A nurse is conducting a health promotion program for adolescents to educate them about the hazards of smoking. When describing the effects on the respiratory system, which of the following would the nurse most likely include? A) Decreased production of mucus B) Inhibition of mucus removal C) Increase in the mucous escalator D) Inhibition of bacterial colonization B The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of A) Atelectasis B) Bronchospasm C) Croup D) Epiglottitis A The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. What additional assessment would the nurse expect to observe? A) Crackles in the lower lobes B) Inspiratory stridor C) Expiratory stridor D) Wheezing in the upper lobes A A nurse is caring for an older adult client who is to be discharged from the health care facility. The client has been prescribed the use of a liquid oxygen unit at home to continue with oxygen therapy. What should the nurse tell the client regarding the potential problems of using a liquid oxygen unit? Select all that applY A) Liquid oxygen may leak during warm weather. B) The unit may give off a bad smell if not cleaned regularly. C) The unit's outlet may become occluded because of frozen moisture. D) Portable liquid oxygen is more expensive. E) The unit may require a secondary source of oxygen. A C D A nurse is educating a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the teaching plan? A) Instruct the client to inhale normally and then place the lips securely around the mouthpiece. B) Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose. C) When the client cannot inhale anymore, the patient should hold his or her breath and count to 10. D) Encourage the client to perform incentive spirometry two to three times every one to two hours, if possible. B A nurse is delivering oxygen to a client via an oxygen mask. Which of the following is a recommended guideline for this procedure? A) Adjust the mask so it fits tightly around the face. B) For a mask with a reservoir, fill the reservoir half-full of oxygen. C) Remove the mask and dry the skin every two to three hours if the oxygen is running continuously. D) If the client is experiencing redness around the mask, remove and apply powder to the mask. C A physician is choosing a chest drainage system for a client who is ambulating daily. Which of the following systems would be the best choice for this client? A) Traditional water seal B) Wet suction C) Dry suction water seal D) Dry suction/one-way valve system D A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply. A) Monitor the client's respiratory rate. B) Note the amount of oxygen administered. C) Check the symmetry of the client's chest. D) Observe the breathing pattern and effort. E) Check the devices used to deliver oxygen. A C D A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate could be expected based on the developmental level of this client? A) 15 to 25 breaths/minute B) 16 to 20 breaths/minute C) 20 to 44 breaths/minute D) 30 to 55 breaths/minute D Which one of the following types of anesthesia would be the best choice for an older adult undergoing surgery of the lower abdomen? A. General anesthesia B. Topical and local anesthesia C. Moderate sedation/analgesia D. Regional anesthesia D Which one of the following lung values is the amount of air contained within the lungs at maximum inspiration? A. Vital capacity B. Total lung capacity C. Residual volume D. Peak expiratory flow rate B •The nurse is making morning rounds and has discovered that the total parenteral nutrition (TPN) was off and not running into the central line. What assessment should the nurse watch the client carefully for? A. Excessive thirst and urination B. Fever and chills C. Shakiness and diaphoresis D. Hypertension and crackles C A perioperative nurse is preparing a patient for surgery for treatment of a ruptured spleen as the result of an automobile crash. For what type of surgery would the nurse prepare this patient? a. Minor, diagnostic b. Minor, elective c. Major, emergency d. Major, palliative C A nurse is preparing a patient for a cesarean section and teaches her the effects of the regional anesthesia she will be receiving. Which effects would the nurse expect? Select all that apply. a. Loss of consciousness b. Relaxation of skeletal muscles c. Reduction or loss of reflex action d. Localized loss of sensation e. Prolonged pain relief after other anesthesia wears off f. Infiltrates the underlying tissues in an operative area C D A nurse has been asked to witness a patient signature on an informed consent form for surgery. What information should be included on the form? Select all that apply. a. The option of nontreatment b. The underlying disease process and its natural course c. Notice that once the form is signed, the patient cannot withdraw the consent d. Explanation of the guaranteed outcome of the procedure or treatment e. Name and qualifications of the provider of the procedure or treatment f. Explanation of the risks and benefits of the procedure or treatment A B E F A 72-year-old woman who is scheduled for a hip replacement is taking several medications on a regular basis. Which drug category might create a surgical risk for this patient? a. Anticoagulants b. Antacids c. Laxatives d. Sedatives A A nurse is caring for an obese patient who has had surgery. The nurse monitors this patient for what postoperative complication? a. Anesthetic agent interactions b. Impaired wound healing c. Hemorrhage d. Gas pains B A responsibility of the nurse is the administration of preoperative medications to patients. Which statements describe the action of these medications? Select all that apply. a. Diazepam is given to alleviate anxiety. b. Ranitidine is given to facilitate patient sedation. c. Atropine is given to decrease oral secretions. d. Morphine is given to depress respiratory function. e. Cimetidine is given to prevent laryngospasm. f. Fentanyl citrate-droperidol is given to facilitate a sense of calm. A C F A nurse is providing teaching for a patient scheduled to have same-day surgery. Which teaching method would be most effective in preoperative teaching for ambulatory surgery? a. Lecture b. Discussion c. Audiovisuals d. Written instructions D A 70-year-old male is scheduled for surgery. He says to the nurse, "I am so frightened—what if I don't wake up?" What would be the nurse's best response? a. "You have a wonderful doctor." b. "Let's talk about how you are feeling." c. "Everyone wakes up from surgery!" d. "Don't worry, you will be just fine." B A nurse is explaining pain control methods to a patient undergoing a bowel resection. The patient is interested in the PCA pump and asks the nurse to explain how it works. What would be the nurse's correct response? a. "The pump allows the patient to be completely free of pain during the postoperative period." b. "The pump allows the patient to take unlimited amounts of medication as needed." c. "The pump allows the patient to choose the type of medication given postoperatively." d. "The pump allows the patient to self-administer limited doses of pain medication." D A patient had a surgical procedure that necessitated a thoracic incision. The nurse anticipates that the patient will have a higher risk for postoperative complications involving which body system? a. Respiratory system b. Circulatory system c. Digestive system d. Nervous system A While assessing a patient in the PACU, a nurse notes increased wound drainage, restlessness, a decreasing blood pressure, and an increase in the pulse rate. The nurse interprets these findings as most likely indicating: a. Thrombophlebitis b. Atelectasis c. Infection d. Hemorrhage D A patient tells the nurse she is having pain in her right lower leg. How does the nurse determine if the patient has developed a deep vein thrombosis (DVT)? a. By palpating the skin over the tibia and fibula b. By documenting daily calf circumference measurements c. By recording vital signs obtained four times a day d. By noting difficulty with ambulation B A scrub nurse is assisting a surgeon with a kidney transplant. What are the patient responsibilities of the scrub nurse? Select all that apply. a. Maintaining sterile technique b. Draping and handling instruments and supplies c. Identifying and assessing the patient on admission d. Integrating case management e. Preparing the skin at the surgical site f. Providing exposure of the operative area A B Older adults often have reduced vital capacity as a result of normal physiologic changes. Which nursing intervention would be most important for the postoperative care of an older surgical patient specific to this change? a. Take and record vital signs every shift b. Turn, cough, and deep breathe every 4 hours c. Encourage increased intake of oral fluids d. Assess bowel sounds daily B A nurse is explaining the rationale for performing leg exercises after surgery. Which reason would the nurse include in the explanation? a. Promote respiratory function b. Maintain functional abilities c. Provide diversional activities d. Increase venous return D A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient's height is 5′6″ and his current weight is 325 lb. What would the nurse document as his BMI? A. 50.5 B. 52.4 C. 54.5 D. 55.2 B A nurse is evaluating a patient following the administration of an enteral feeding. Which findings are normal and are criteria that indicate patient tolerance to the feeding? Select all that apply. A. Absence of nausea, vomiting B. Weight gain C. Bowel sounds within normal range D. Large amount of gastric residue E. Absence of diarrhea and constipation F. Slight abdominal pain and distention A C E A nurse is feeding an older adult patient who has dementia. Which intervention should the nurse perform to facilitate this process? A. Stroke the underside of the patient's chin to promote swallowing. B. Serve meals in different places and at different times. C. Offer a whole tray of various foods to choose from. D. Avoid between-meal snacks to ensure hunger at mealtime. A A patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating appetite in this patient? A. Administering pain medication after meals. B. Encouraging food from home when possible. C. Scheduling his respiratory therapy before each meal. D. Reinforcing the importance of his eating exactly what is delivered to him. B A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient? A. Feed the patient solids first and then liquids last. B. Place the head of the bed at a 30-degree angle during feeding. C. Puree all foods to a liquid consistency. D. Provide a 30-minute rest period prior to mealtime. D A nurse is evaluating patients to determine their need for parenteral nutrition (PN). Which patients would be the best candidates for this type of nutritional support? Select all that apply. A. A patient with irritable bowel syndrome who has intractable diarrhea B. A patient with celiac disease not absorbing nutrients from the GI tract C. A patient who is underweight and needs short-term nutritional support D. A patient who is comatose and needs long-term nutritional support E. A patient who has anorexia and refuses to take foods via the oral route F. A patient with burns who has not been able to eat adequately for 5 days A B F A nurse is feeding a patient who states that she is feeling nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? A. Remove the tray from the room. B. Administer an antiemetic and encourage the patient to take small amounts. C. Explore with the patient why she does not want to eat her food. D. Offer high-calorie snacks such as pudding and ice cream. A A patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition? A. Vitamin B malnutrition B. Obesity C. Dehydration D. Vitamin C deficiency A A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly? A. The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site. B. The nurse wets a washcloth and washes the area around the tube with soap and water. C. The nurse adjusts the external disk every 3 hours to avoid crusting around the tube. D. The nurse tapes a gauze dressing over the site after cleansing it. A A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient’s diet should not be advanced? A. The patient consumed 75% of the liquids on her breakfast tray. B. The patient tells you she is hungry. C. The patient’s abdomen is soft, nondistended, with bowel sounds. D. The patient reports fullness and diarrhea after breakfast. D A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube? A. Auscultate the bowel sounds. B. Measure the gastric aspirate pH. C. Measure the amount of residual in the tube. D. Obtain an order for a radiographic examination of the tube. D Which nursing diagnosis would be most appropriate for a patient with a body mass index (BMI) of 18? A. Risk for Imbalanced Nutrition: More Than Body Requirements B. Imbalanced Nutrition: More Than Body Requirements C. Readiness for Enhanced Nutrition D. Imbalanced Nutrition: Less Than Body Requirements D A nurse nutritionist is collecting assessment data for a patient who complains of "tiredness" and appears malnourished. The nurse orders tests for hemoglobin and hematocrit. What condition might these tests confirm? A. Malabsorption B. Anemia C. Protein depletion D. Reduction in total muscle mass B A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse’s next action following this assessment? A. Use warm water or air and gentle pressure to remove the clog. B. Use a stylet to unclog the tubes. C. Administer cola to remove the clog. D. Replace the tube with a new one. A A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed? A. A 19-year-old patient who is a vegan B. An older adult patient who takes daily nutritional drinks C. A 43-year-old patient who takes ginkgo biloba and an aspirin daily D. An infant who is breastfeeding C A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? A. Dyspnea B. Hypotension C. Decreased respiratory rate D. Decreased pulse rate A A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? A. The patient vomits during suctioning. B. The secretions appear to be stomach contents. C. The catheter touches an unsterile surface. D. A nosebleed is noted with continued suctioning. D A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? A. Remove the catheter. B. Notify the primary care provider. C. Check that the airway is the appropriate size for the patient. D. Place the patient on his or her back. A A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? A. The age of the patient B. The size of the endotracheal tube C. The type of secretions to be suctioned D. The height and weight of the patient B A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? A. Thoracentesis B. Pulse oximetry C. Diffusion capacity D. Maximal respiratory pressure B A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? A. Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone. B. Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability. C. Teach the patient to take short shallow breaths when performing hygiene measures. D. Group personal care activities into smaller steps, allowing rest periods between activities. D A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. A. Refrain from exercise. B. Reduce anxiety. C. Eat meals 1 to 2 hours prior to breathing treatments. D. Eat a high-protein/high-calorie diet. E. Maintain a high-Fowler's position when possible. F. Drink 2 to 3 pints of clear fluids daily. B D E A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? A. A postoperative adult B. An adult with COPD C. A teenager with cystic fibrosis D. A child with pneumonia C A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. A. "I will be careful not to shake up the canister before using it." B. "I will hold the canister upside down when using it." C. "I will inhale the medication through my nose." D. "I will continue to inhale when the cold propellant is in my throat." E. "I will only inhale one spray with one breath." F. "I will activate the device while continuing to inhale." D E F A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? A. The nurse assures that the oxygen is flowing into the prongs. B. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. C. The nurse encourages the patient to breathe through the nose with the mouth closed. D. The nurse adjusts the flow rate to 6 L/min or more. C A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? A. Instruct the assistant to notify the primary care provider. B. Assess the patient's vital signs. C. Remove the tape, adjust the depth to ordered depth and reapply the tape. D. No action is required as depth will adjust automatically. C What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? A. Checking the amount of oxygen in the cylinder before using it B. Using a cylinder for a patient transfer that indicates available oxygen is 500 psi C. Placing the oxygen cylinder on the stretcher next to the patient D. Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight A A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? A. Notify the health care provider. B. Apply an occlusive dressing on the site. C. Assess the patient for signs of respiratory distress. D. Put on gloves and insert the chest tube in a bottle of sterile saline. D An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? A. Tilt the patient's head forward. B. Hold the mask tightly over the patient's nose and mouth. C. Pull the patient's jaw backward. D. Compress the bag twice the normal respiratory rate for the patient. B Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. A. Closely assess the patient before, during, and after the procedure. B. Hyperoxygenate the patient before and after suctioning. C. Limit the application of suction to 20 to 30 seconds. D. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. E. Use an appropriate suction pressure (80 to 150 mm Hg). F. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube. A B D E A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids B. Instruct the client to tuck their chin when swallowing C. Have the client use a straw D. Encourage the client to lie down and rest after meals B A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates D A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed Broccoli C. Vanilla Custard D. Lentil soup C A nurse in a senior center is counseling a group of older adults about their nutritional needs & considerations. Which of the following info should the nurse include? Select all that apply A. Older adults are more prone to dehydration than younger adults are B. Older adults need the same amount of most vitamins & minerals as younger adults do C. Many older men & women need calcium supplementation D. Older adults need more calories than they did when they were younger E. Older adults should consume a diet low in carbs A B C A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Hypertension A B D E A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? Select all that apply) A. Apply petroleum jelly around and inside the nares B. Remove the nasal cannula during mealtimes C. Check the position of the cannula frequently D. Report any nausea or difficulty breathing E. Post "No Smoking" signs in prominent locations C D E A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow B. Assist the client to Fowler's position C. Promote removal of pulmonary secretions D. Obtain a specimen for arterial blood gases B A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply) A. Apply suction while withdrawing the catheter B. Perform suctioning on a routine basis every 2 to 3 hours C. Maintain medical asepsis during suctioning D. Use a new catheter for each suctioning attempt E. Apply suction for 10 to 15 seconds A D E A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure B. Use surgical asepsis to remove and clean the inner cannula C. Clean the outer cannula surfaces in a circular motion from the stoma site outward D. Replace the tracheostomy ties with new ties E Cut a slit in gauze squares to place beneath the tube holder A B C A nurse is delivering an enteral feeding to a client who has an NG tube in place for the intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated." A A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds B. Stop the feeding C. Obtain a chest x-ray D. Initiate oxygen therapy B A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been open B. Verify the placement of the NG tube C. Confirm that the client does not have diarrhea D. Make sure the client is alert and oriented. B A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feedings? (Select all that apply) A. Auscultate bowel sounds B. Assist the client to an upright position C. Test the pH of gastric aspirate D. Warm the formula to body temperature E. Discard any residual gastric contents A B C A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply). A. Review a signal the client can use if feeling any distress B. Lay a towel across the client's chest C. Administer oral pain medication D. Obtain a Dobhoff tube for insertion E. Have a petroleum-based lubricant available