4 Test Questions And Answers Verified 100%
Correct
In preparing a client with head and neck cancer (pharyngeal) for radiation therapy, which side
effects does the nurse teach the client to expect? Select all that apply.
A. Scalp and eyebrow alopecia
B. Taste sensation loss or changes
C. Bloody and purulent sinus drainage
D. Increased risk for skin breakdown
E. Moderate weight gain
F. Increased risk for cavities
G. Gastroesophageal reflux
H. A persistent blue tinge to the skin and mucous membranes around the mouth - ANSWER B.
Taste sensation loss or changes
D. Increased risk for skin breakdown
F. Increased risk for cavities
When ANSWERing the call light for a client on bedrest, the nurse finds the client's visitor
unconscious on the floor with no discernable pulse and not breathing. The nurse estimates that at
least 2 minutes have passed since the client's light first came on. What is the nurse's priority
action?
A. Initiate CPR with chest compressions.
B. Perform an abdominal thrust maneuver.
C. Assess the visitor for the presence of a head injury.
D. Ask the client what event led up to the visitor's fall. - ANSWER A. Initiate CPR with chest
compressions.
Which information is most relevant for the nurse to teach a client about CPAP therapy for OSA?
Select all that apply.
A. Avoid alcoholic beverages or drugs that make you sleepy within 3 hours of bed time.
B. Clean the mask device daily.
C. Ensure your mask device fits tightly enough to prevent air leaks.
D. Keep open flames such as candles out of the room when CPAP is in use.
E. Seal the mask edges to your face with petroleum jelly.
F. Use only sterile water in the humidifier tank.
G. Use the CPAP during all sleep periods, especially in bed.
,H. Do not share your mask or tubing system with others. - ANSWER B. Clean the mask device
daily.
C. Ensure your mask device fits tightly enough to prevent air leaks.
G. Use the CPAP during all sleep periods, especially in bed.
H. Do not share your mask or tubing system with others.
Which nursing action has the highest priority when caring for a client with any type of facial or
laryngeal trauma? A. Managing pain
B. Providing nutrition
C. Assessing self-image
D. Maintaining a patent airway - ANSWER D. Maintaining a patent airway
A client who underwent radical neck surgery for head and neck cancer 5 days ago tells the nurse
that he is worried because his right shoulder is lower than the left and does not go back into place
when he tries to raise it. What is the nurse's best response?
A. "I will notify the surgeon right away because some leftover tumor must be pressing on
the nerve."
B. "The nerve to the shoulder was removed during surgery. Physical therapy will help you to
use other muscles to regain some motion."
C. "This problem is not related to your surgery. If it persists after you go home you will
need to see your primary health care provider about it."
D. "Your time under anesthesia was long and you are not yet fully recovered. It is likely you
will regain full motion in that shoulder by the end of the week." - ANSWER B. "The nerve to the
shoulder was removed during surgery. Physical therapy will help you to use other muscles to
regain some motion."
The emergency department nurse is assessing a client who has sustained a blunt injury to the
chest wall. Which finding indicates the presence of a pneumothorax in this client? a. A low
respiratory rate
b. Diminished breath sounds
c. The presence of a barrel chest
d. A sucking sound at the site of injury - ANSWER b. Diminished breath sounds
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive
pulmonary disease. Which findings would the nurse expect to note on assessment of this client?
Select all that apply.
a. A low arterial PCo2 level
b. A hyperinflated chest noted on the chest x-ray
c. Decreased oxygen saturation with mild exercise
d. A widened diaphragm noted on the chest x-ray
,e. Pulmonary function tests that demonstrate increased vital capacity - ANSWER b. A
hyperinflated chest noted on the chest x-ray
c. Decreased oxygen saturation with mild exercise
The nurse is preparing a list of home care instructions for a client who has been hospitalized and
treated for tuberculosis. Which instructions should the nurse include on the list? Select all that
apply.
a. Activities should be resumed gradually.
b. Avoid contact with other individuals, except family members, for at least 6 months.
c. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
d. Respiratory isolation is not necessary, because family members already have been exposed.
e. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.
f. When 1 sputum culture is negative, the client is no longer considered infectious and usually
can return to former employment. - ANSWER a. Activities should be resumed gradually. c. A
sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
d. Respiratory isolation is not necessary, because family members already have been exposed.
e. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags.
The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the
client, should be reported immediately to the primary health care provider? a. Dry cough
b. Hematuria
c. Bronchospasm
d. Blood-streaked sputum - ANSWER c. Bronchospasm
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The
nurse should expect to note which finding? a. Slow, deep respirations
b. Rapid, deep respirations
c. Paradoxical respirations
d. Pain, especially with inspiration - ANSWER d. Pain, especially with inspiration
A client with a chest injury has suffered flail chest. The nurse assesses the client for which most
distinctive sign of flail chest? a. Cyanosis
b. Hypotension
c. Paradoxical chest movement
d. Dyspnea, especially on exhalation - ANSWER c. Paradoxical chest movement
The nurse is assessing a client with multiple trauma who is at risk for developing acute
respiratory distress syndrome. The nurse should assess for which earliest sign of acute
respiratory distress syndrome? a. Bilateral wheezing
b. Inspiratory crackles
, c. Intercostal retractions
d. Increased respiratory rate - ANSWER d. Increased respiratory rate
The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has
been receiving medication for 2 weeks. The nurse determines that the client has understood the
information if the client makes which statement?
a. "I need to continue medication therapy for 1 month."
b. "I can't shop at the mall for the next 6 months."
c. "I can return to work if a sputum culture comes back negative."
d. "I should not be contagious after 2 to 3 weeks of medication therapy." - ANSWER d. "I should
not be contagious after 2 to 3 weeks of medication therapy."
The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse
should wear which items when performing this care? a. Surgical mask and gloves
b. Particulate respirator, gown, and gloves
c. Particulate respirator and protective eyewear
d. Surgical mask, gown, and protective eyewear - ANSWER b. Particulate respirator, gown, and
gloves
A client has experienced pulmonary embolism. The nurse should assess for which symptom,
which is most commonly reported? a. Hot, flushed feeling
b. Sudden chills and fever
c. Chest pain that occurs suddenly
d. Dyspnea when deep breaths are taken - ANSWER c. Chest pain that occurs suddenly
A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test
(TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the
result as which finding? a. Positive
b. Negative
c. Inconclusive
d. Need for repeat testing - ANSWER a. Positive
A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse
should assess the client for which expected finding? a. Dyspnea
b. Headache
c. Weight gain
d. Hypothermia - ANSWER a. Dyspnea