NUR 504 EXAM 3
NUR 504 EXAM 3 NEWEST 2025/2026
COMPLETE ALL 360 QUESTIONS AND
CORRECT DETAILED ANSWERS
|ALREADY GRADED A+||ALREADY
GRADED A+
A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects
related to an acid-base imbalance would the nurse assess? (Select all that apply.)
a. Positive Chvostek sign
b. Elevated blood pressure
c. Bradycardia
d. Increased muscle strength
e. Anxiety and irritability
f. Tetany
ANS: A, E
A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Signs and
symptoms of metabolic alkalosis include positive Chvostek sign, normal or low blood
pressure, increased heart rate, skeletal muscle weakness, possible tetany and seizures, and
anxiety and irritability.
A nurse is planning care for a client who is lethargic and confused. The client's arterial blood
gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L (19
mmol/L). Which questions would the nurse ask the client and spouse when developing the
plan of care? (Select all that apply.)
a. "Are you taking any antacid medications?"
b. "Is your spouse's current behavior typical?"
c. "Do you drink any alcoholic beverages?"
d. "Have you been participating in strenuous activity?"
e. "Are you experiencing any shortness of breath?"
ANS: B, C, D
This client's symptoms of lethargy and confusion are related to a state of metabolic acidosis.
The nurse would ask the client's spouse or family members if the client's behavior is typical
for him or her, and establish a baseline for comparison with later assessment findings. The
nurse would also assess for alcohol intake because alcohol can cause metabolic acidosis.
Excessive and strenuous activity can lead to overproduction of hydrogen ions. The other
options are not causes of metabolic acidosis.
A+ TEST BANK 1
, NUR 504 EXAM 3
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the
client's face is puffy and the eyelids are swollen. What action by the nurse takes best?
a. Assess the client's oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest.
ANS: A
This client may have subcutaneous emphysema, which is air that leaks into the tissues
surrounding the tracheostomy. The nurse would first assess the client's oxygen saturation and
other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the
upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response
Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles
are noted. What action by the nurse is best?
a. Elevate the head of the client's bed.
b. Measure and compare cuff pressures.
c. Place the client on NPO status.
d. Request that the client have a swallow study.
ANS: B
Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to
dilation of the tracheal passage. This can be manifested by food particles seen in secretions or
by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff
inflated. The nurse would measure the pressures and compare them to previous ones to detect
a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a
swallow study will not correct this situation.
A nurse is providing tracheostomy care. What action by the nurse requires intervention by
the charge nurse?
a. Holding the device securely when changing ties
b. Suctioning the client first if secretions are present
c. Tying a square knot at the back of the neck
d. Using half-strength peroxide for cleansing
ANS: C
To prevent pressure injuries and for client safety, when ties are used that must be knotted, the
knot would be placed at the side of the client's neck, not in back. The other actions are
appropriate.
A nurse assesses several clients who have a history of respiratory disorders. Which client
would the nurse assess first?
a. A 66-year-old client with a barrel chest and clubbed fingernails
b. A 48-year-old client with an oxygen saturation level of 92% at rest
A+ TEST BANK 2
, NUR 504 EXAM 3
c. A 35-year-old client who reports orthopnea in bed
d. A 27-year-old client with a heart rate of 120 beats/min
ANS: D
Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available.
A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not
considered an acute finding. Orthopnea at night in bed is breathlessness when lying down but
is not an acute finding at this moment.
While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a
nurse notices that the chest tube is dislodged. Which action by the nurse is best?
a. Assess for drainage from the site.
b. Cover the insertion site with sterile gauze.
c. Contact the primary health care provider.
d. Reinsert the tube using sterile technique.
ANS: B
Immediately covering the insertion site helps prevent air from entering the pleural space and
causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering
the chest. The nurse would not leave the client to obtain a suture kit. An occlusive dressing
may cause a tension pneumothorax. The nurse does not need to assess the site at this moment.
The primary health care provider would be called to reinsert the chest tube or prescribe other
treatment options.
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep
breaths because of the pain. What action would the nurse take?
a. Ambulate the client in the hallway to promote deep breathing.
b. Auscultate the client's anterior and posterior lung fields.
c. Encourage the client to take shallow breaths to help with the pain.
d. Administer pain medication and encourage the client to take deep breaths.
ANS: D
A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse
would provide pain medication to minimize discomfort and encourage the client to take deep
breaths. The other responses do not address the client's discomfort and need to take deep
breaths to prevent complications.
A nurse cares for a client who has a pleural chest tube. What action would the nurse take to
ensure safe use of this equipment?
a. Strip the tubing to minimize clot formation and ensure patency.
b. Secure tubing junctions with clamps to prevent accidental disconnections.
c. Connect the chest tube to wall suction as prescribed by the primary health care
provider.
d. Keep padded clamps at the bedside for use if the drainage system is interrupted.
A+ TEST BANK 3
, NUR 504 EXAM 3
ANS: D
Padded clamps would be kept at the bedside for use if the drainage system becomes dislodged
or is interrupted. The nurse would never strip the tubing. Tubing junctions would be taped, not
clamped. Wall suction would be set at the level indicated by the device's manufacturer, not
the primary health care provider.
A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the
nurse's immediate intervention? (Select all that apply.)
a. Production of pink sputum
b. Tracheal deviation
c. Pain at insertion site
d. Sudden onset of shortness of breath
e. Drainage greater than 70 mL/hr
f. Disconnection at Y site
ANS: B, D, E, F
Immediate intervention is warranted if the client has tracheal deviation because this could
indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of
the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could
indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing.
Production of pink sputum and pain at the insertion site are not signs/symptoms that would
require immediate intervention.
A nurse cares for a client who is prescribed an intravenous prostacyclin agent for pulmonary
artery hypertension. What actions would the nurse take to ensure the client's safety while on
this medication? (Select all that apply.)
a. Keep an intravenous line dedicated strictly to the infusion.
b. Teach the client that this medication increases pulmonary pressures.
c. Ensure that there is always a backup drug cassette available.
d. Start a large-bore peripheral intravenous line.
e. Use strict aseptic technique when using the drug delivery system.
ANS: A, C, E
Intravenous prostacyclin agents would be administered to a client with pulmonary artery
hypertension through a central venous catheter with a dedicated intravenous line for this
medication. Death has been reported when the drug delivery system is interrupted even
briefly; therefore, a backup drug cassette would also be available. The nurse would use strict
aseptic technique when using the drug delivery system. The nurse would teach the client that
this medication decreases pulmonary pressures and increases lung blood flow.
A nurse is assessing a client with lung cancer. What nonpulmonary signs and symptoms
would the nurse be aware of? (Select all that apply.)
a. Gynecomastia in male patients
b. Frequent shaking and sweating relieved by eating
c. Positive Chvostek and Trousseau signs
A+ TEST BANK 4
NUR 504 EXAM 3 NEWEST 2025/2026
COMPLETE ALL 360 QUESTIONS AND
CORRECT DETAILED ANSWERS
|ALREADY GRADED A+||ALREADY
GRADED A+
A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects
related to an acid-base imbalance would the nurse assess? (Select all that apply.)
a. Positive Chvostek sign
b. Elevated blood pressure
c. Bradycardia
d. Increased muscle strength
e. Anxiety and irritability
f. Tetany
ANS: A, E
A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Signs and
symptoms of metabolic alkalosis include positive Chvostek sign, normal or low blood
pressure, increased heart rate, skeletal muscle weakness, possible tetany and seizures, and
anxiety and irritability.
A nurse is planning care for a client who is lethargic and confused. The client's arterial blood
gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L (19
mmol/L). Which questions would the nurse ask the client and spouse when developing the
plan of care? (Select all that apply.)
a. "Are you taking any antacid medications?"
b. "Is your spouse's current behavior typical?"
c. "Do you drink any alcoholic beverages?"
d. "Have you been participating in strenuous activity?"
e. "Are you experiencing any shortness of breath?"
ANS: B, C, D
This client's symptoms of lethargy and confusion are related to a state of metabolic acidosis.
The nurse would ask the client's spouse or family members if the client's behavior is typical
for him or her, and establish a baseline for comparison with later assessment findings. The
nurse would also assess for alcohol intake because alcohol can cause metabolic acidosis.
Excessive and strenuous activity can lead to overproduction of hydrogen ions. The other
options are not causes of metabolic acidosis.
A+ TEST BANK 1
, NUR 504 EXAM 3
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the
client's face is puffy and the eyelids are swollen. What action by the nurse takes best?
a. Assess the client's oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest.
ANS: A
This client may have subcutaneous emphysema, which is air that leaks into the tissues
surrounding the tracheostomy. The nurse would first assess the client's oxygen saturation and
other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the
upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response
Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles
are noted. What action by the nurse is best?
a. Elevate the head of the client's bed.
b. Measure and compare cuff pressures.
c. Place the client on NPO status.
d. Request that the client have a swallow study.
ANS: B
Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to
dilation of the tracheal passage. This can be manifested by food particles seen in secretions or
by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff
inflated. The nurse would measure the pressures and compare them to previous ones to detect
a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a
swallow study will not correct this situation.
A nurse is providing tracheostomy care. What action by the nurse requires intervention by
the charge nurse?
a. Holding the device securely when changing ties
b. Suctioning the client first if secretions are present
c. Tying a square knot at the back of the neck
d. Using half-strength peroxide for cleansing
ANS: C
To prevent pressure injuries and for client safety, when ties are used that must be knotted, the
knot would be placed at the side of the client's neck, not in back. The other actions are
appropriate.
A nurse assesses several clients who have a history of respiratory disorders. Which client
would the nurse assess first?
a. A 66-year-old client with a barrel chest and clubbed fingernails
b. A 48-year-old client with an oxygen saturation level of 92% at rest
A+ TEST BANK 2
, NUR 504 EXAM 3
c. A 35-year-old client who reports orthopnea in bed
d. A 27-year-old client with a heart rate of 120 beats/min
ANS: D
Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available.
A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not
considered an acute finding. Orthopnea at night in bed is breathlessness when lying down but
is not an acute finding at this moment.
While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a
nurse notices that the chest tube is dislodged. Which action by the nurse is best?
a. Assess for drainage from the site.
b. Cover the insertion site with sterile gauze.
c. Contact the primary health care provider.
d. Reinsert the tube using sterile technique.
ANS: B
Immediately covering the insertion site helps prevent air from entering the pleural space and
causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering
the chest. The nurse would not leave the client to obtain a suture kit. An occlusive dressing
may cause a tension pneumothorax. The nurse does not need to assess the site at this moment.
The primary health care provider would be called to reinsert the chest tube or prescribe other
treatment options.
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep
breaths because of the pain. What action would the nurse take?
a. Ambulate the client in the hallway to promote deep breathing.
b. Auscultate the client's anterior and posterior lung fields.
c. Encourage the client to take shallow breaths to help with the pain.
d. Administer pain medication and encourage the client to take deep breaths.
ANS: D
A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse
would provide pain medication to minimize discomfort and encourage the client to take deep
breaths. The other responses do not address the client's discomfort and need to take deep
breaths to prevent complications.
A nurse cares for a client who has a pleural chest tube. What action would the nurse take to
ensure safe use of this equipment?
a. Strip the tubing to minimize clot formation and ensure patency.
b. Secure tubing junctions with clamps to prevent accidental disconnections.
c. Connect the chest tube to wall suction as prescribed by the primary health care
provider.
d. Keep padded clamps at the bedside for use if the drainage system is interrupted.
A+ TEST BANK 3
, NUR 504 EXAM 3
ANS: D
Padded clamps would be kept at the bedside for use if the drainage system becomes dislodged
or is interrupted. The nurse would never strip the tubing. Tubing junctions would be taped, not
clamped. Wall suction would be set at the level indicated by the device's manufacturer, not
the primary health care provider.
A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the
nurse's immediate intervention? (Select all that apply.)
a. Production of pink sputum
b. Tracheal deviation
c. Pain at insertion site
d. Sudden onset of shortness of breath
e. Drainage greater than 70 mL/hr
f. Disconnection at Y site
ANS: B, D, E, F
Immediate intervention is warranted if the client has tracheal deviation because this could
indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of
the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could
indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing.
Production of pink sputum and pain at the insertion site are not signs/symptoms that would
require immediate intervention.
A nurse cares for a client who is prescribed an intravenous prostacyclin agent for pulmonary
artery hypertension. What actions would the nurse take to ensure the client's safety while on
this medication? (Select all that apply.)
a. Keep an intravenous line dedicated strictly to the infusion.
b. Teach the client that this medication increases pulmonary pressures.
c. Ensure that there is always a backup drug cassette available.
d. Start a large-bore peripheral intravenous line.
e. Use strict aseptic technique when using the drug delivery system.
ANS: A, C, E
Intravenous prostacyclin agents would be administered to a client with pulmonary artery
hypertension through a central venous catheter with a dedicated intravenous line for this
medication. Death has been reported when the drug delivery system is interrupted even
briefly; therefore, a backup drug cassette would also be available. The nurse would use strict
aseptic technique when using the drug delivery system. The nurse would teach the client that
this medication decreases pulmonary pressures and increases lung blood flow.
A nurse is assessing a client with lung cancer. What nonpulmonary signs and symptoms
would the nurse be aware of? (Select all that apply.)
a. Gynecomastia in male patients
b. Frequent shaking and sweating relieved by eating
c. Positive Chvostek and Trousseau signs
A+ TEST BANK 4
