EDAPT: NCLEX READINESS: PHYSIOLOGICAL
ADAPTATION QUESTIONS WITH 100%
ACCURATE ANSWERS
The nurse in the emergency department (ED) is caring for a 24-year-old male client.
The client is at highest risk for acute development of __________. - Accurate answers Hemothorax
Review the electronic health record (EHR). For each potential nursing intervention, specify whether the
intervention is indicated or contraindicated in the client's care plan. - Accurate answers
*Indicated:*
Prepare the client for sterile chest tube insertion.
Administer intravenous pain medication as prescribed.
Request an order to increase the oxygen flow rate.
*Contraindicated:*
Prepare the client for defibrillation.
Place the client in supine position.
The nurse is planning care for the client post-chest tube insertion. Which nursing actions should be
included in the client's care? Select all that apply. - Accurate answers Provide pharmacological and
nonpharmacological pain management.
Monitor chest tube drainage level per agency policy.
Encourage use of incentive spirometry every hour while awake.
Assess breath sounds at given intervals per agency policy.
Observe for crepitus around chest tube insertion site.
The nurse is caring for a set of clients who had arterial blood gases (ABG) collected. Which result would
require immediate follow-up by the nurse? - Accurate answers pH: 7.5, PaCO2: 30, HCO3-: 24
The nurse is planning a staff education program about ventilator care for critical care nurses. What
information should the nurse include? Select all that apply. - Accurate answers "Ensure the client is
receiving adequate nutrition while ventilated."
"Perform oral care with chlorhexidine daily."
"Consistently assess the client's pain and sedation needs."
"Provide daily sedation vacations while assessing readiness for extubation."
, "Hyperoxygenate the client before and after suctioning is performed."
The nurse is caring for a group of clients. Which client has the highest risk of developing respiratory
complications? - Accurate answers 6-month-old client with aplastic anemia and seizures
The nurse is caring for a pediatric client with asthma. The nurse understands this disease causes
__________ that is characterized by __________. - Accurate answers Intermittent reversible
airway obstruction
Airway inflammation, bronchospasm, and increased mucus production
The nurse is caring for an older adult client who recently underwent anesthesia for a bronchoscopy with
a biopsy. Complete the sentence by choosing from the list of options.
The nurse understands the highest priority for this client is __________. - Accurate answers Early
mobilization
The nurse is educating a client about proper use of an incentive spirometer. For each statement by the
nurse, click to indicate if the statement is appropriate or inappropriate. - Accurate answers
*Appropriate:*
"Place the mouthpiece in your mouth and make sure your lips are closed tightly around it."
"Sit up on the edge of your bed or on a chair when you use the incentive spirometer."
"Hold the incentive spirometer in an upright position while you use it."
*Inappropriate:*
"Breathe out slowly and for as long as you can through your mouth."
The nurse in a community-based setting is teaching clients over 65 years of age about ways to promote
respiratory health. Drag the information the nurse should include to the boxes on the right. - Accurate
answers Visit your healthcare provider for routine checkups yearly and as needed.
Brush your teeth at least twice daily and visit the dentist every 6 months.
Being physically active can help keep your lungs healthy and strong.
Clean frequently touched surfaces in your home on a consistent basis.
The nurse is preparing to assess the client at the beginning of the shift and reads the following nurse's
note written by the previous shift nurse.
Highlight the assessment findings that require follow-up by the nurse. - Accurate answers "I'm
really nervous about having surgery today."
Breathing is shallow and rapid
P 117
RR 39
BP 150/92
ADAPTATION QUESTIONS WITH 100%
ACCURATE ANSWERS
The nurse in the emergency department (ED) is caring for a 24-year-old male client.
The client is at highest risk for acute development of __________. - Accurate answers Hemothorax
Review the electronic health record (EHR). For each potential nursing intervention, specify whether the
intervention is indicated or contraindicated in the client's care plan. - Accurate answers
*Indicated:*
Prepare the client for sterile chest tube insertion.
Administer intravenous pain medication as prescribed.
Request an order to increase the oxygen flow rate.
*Contraindicated:*
Prepare the client for defibrillation.
Place the client in supine position.
The nurse is planning care for the client post-chest tube insertion. Which nursing actions should be
included in the client's care? Select all that apply. - Accurate answers Provide pharmacological and
nonpharmacological pain management.
Monitor chest tube drainage level per agency policy.
Encourage use of incentive spirometry every hour while awake.
Assess breath sounds at given intervals per agency policy.
Observe for crepitus around chest tube insertion site.
The nurse is caring for a set of clients who had arterial blood gases (ABG) collected. Which result would
require immediate follow-up by the nurse? - Accurate answers pH: 7.5, PaCO2: 30, HCO3-: 24
The nurse is planning a staff education program about ventilator care for critical care nurses. What
information should the nurse include? Select all that apply. - Accurate answers "Ensure the client is
receiving adequate nutrition while ventilated."
"Perform oral care with chlorhexidine daily."
"Consistently assess the client's pain and sedation needs."
"Provide daily sedation vacations while assessing readiness for extubation."
, "Hyperoxygenate the client before and after suctioning is performed."
The nurse is caring for a group of clients. Which client has the highest risk of developing respiratory
complications? - Accurate answers 6-month-old client with aplastic anemia and seizures
The nurse is caring for a pediatric client with asthma. The nurse understands this disease causes
__________ that is characterized by __________. - Accurate answers Intermittent reversible
airway obstruction
Airway inflammation, bronchospasm, and increased mucus production
The nurse is caring for an older adult client who recently underwent anesthesia for a bronchoscopy with
a biopsy. Complete the sentence by choosing from the list of options.
The nurse understands the highest priority for this client is __________. - Accurate answers Early
mobilization
The nurse is educating a client about proper use of an incentive spirometer. For each statement by the
nurse, click to indicate if the statement is appropriate or inappropriate. - Accurate answers
*Appropriate:*
"Place the mouthpiece in your mouth and make sure your lips are closed tightly around it."
"Sit up on the edge of your bed or on a chair when you use the incentive spirometer."
"Hold the incentive spirometer in an upright position while you use it."
*Inappropriate:*
"Breathe out slowly and for as long as you can through your mouth."
The nurse in a community-based setting is teaching clients over 65 years of age about ways to promote
respiratory health. Drag the information the nurse should include to the boxes on the right. - Accurate
answers Visit your healthcare provider for routine checkups yearly and as needed.
Brush your teeth at least twice daily and visit the dentist every 6 months.
Being physically active can help keep your lungs healthy and strong.
Clean frequently touched surfaces in your home on a consistent basis.
The nurse is preparing to assess the client at the beginning of the shift and reads the following nurse's
note written by the previous shift nurse.
Highlight the assessment findings that require follow-up by the nurse. - Accurate answers "I'm
really nervous about having surgery today."
Breathing is shallow and rapid
P 117
RR 39
BP 150/92
