Nur 210: Pharm Exam 1 Study Guide
A nurse preparing to care for a client following chest tube placement. Which of the following items
should be available in the client's room? (Select all that apply)
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing - ANSWER:A, B, C, E
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that
the client's chest tube was accidentally removed. Which of the following actions should the nurse take
first?
A. Place the tubing in sterile water to restore the water seal
B. Apply sterile gauze to the insertion site
C. Place tape around the insertion site
D. Assess the client's respiratory status - ANSWER:B
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following
are expected findings? (Select all that apply)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level - ANSWER:B, C
A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicate that
the drainage system is functioning properly
A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse
instruct the client to do?
A. Lie on his left side
B. Use the incentive spirometer
,C. Cough at regular intervals
D. Perform the Valsalva maneuver - ANSWER:D
A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of
the following should be included in the plan of care? (Select all that apply)
A. Encourage the client to cough every 2 hours
B Check for continuous bubbling in the suction chamber
C. Strip the drainage tubing every 4 hours
D. Clamp the tube once a day
E. Obtain a chest x ray - ANSWER:A, B, E
A nurse is assessing a client who has experienced a gun shot wound. Findings include BP 108/55, HR
124/min, RR 36/min, temperature 38.6 (101.4), and SaO2 95% on oxygen 15L/min via non-rebreather
mask. The client reports dyspnea and pain. The nurse reassess the client 30 minutes later. Which of the
following should the nurse report to the provider? (Select all that apply)
A. Distended neck veins
B. Tracheal deviation
C. Headache
D. Nausea
E. HR 154/min - ANSWER:A, B, E
An increased HR is due to impaired cardiac output as a result of trauma
A nurse is reviewing the prescriptions for a client who has pneumothorax. Which of the following actions
should the nurse perform first?
A. Assess the client's pain
B. Obtain a large-bore IV needle for decompression
C. Administer lorazepam (Ativan)
D. Prepare for chest tube insertion - ANSWER:B
A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the
following should be included in the teaching?
A. notify your provider if you experience weakness
B. You should be able to return to work in 1 week
C. You need to wear a mask when in crowded areas
D. Notify your provider if you experience a cough - ANSWER:D
, A nurse in the emergency department is assessing a client with a suspected flail chest. Which of the
following clinical findings confirm this diagnosis? (Select all that apply)
A. Bradycardia
B. Cyanosis
C. Hypotension
D. Dyspnea
E. Paradoxic chest movement - ANSWER:B, C, D, E
A nurse is orienting a newly licensed nurse who is caring for a client that is receiving mechanical
ventilation, which has been placed on pressure support ventilation (PSV) mode. Which of the following
statements by the newly licensed nurse demonstrates an understanding of PSV?
A. It keep the alveoli open and prevents atelectasis
B. It permits spontaneous ventilation to decrease the work of breathing
C. It is used with clients who have difficulty weaning from the ventilator
D. It delivers a preset ventilatory rate and tidal volume to the client - ANSWER:B
A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early
clinical manifestations of hypoxemia? (Select all that apply)
A. Confusion
B. Pale skin
C. Bradycardia
D. Hypotension
E. Elevated blood pressure - ANSWER:B, E
A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving
mechanical ventilation via a endotracheal tube. Which of the following should the nurse include in the
teaching?
A. Apply a vest restraint if self-extubation is attempted
B. Monitor ventilator settings every 8 hours
C. Document tube placement in centimeters at the angle of jaw
D. Assess breath sounds every 1 to 2 hours - ANSWER:D
A nurse is caring for a client who has dyspnea and is to receive oxygen continuously. Which of the
following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?
A. Nonrebreather mask
A nurse preparing to care for a client following chest tube placement. Which of the following items
should be available in the client's room? (Select all that apply)
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing - ANSWER:A, B, C, E
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that
the client's chest tube was accidentally removed. Which of the following actions should the nurse take
first?
A. Place the tubing in sterile water to restore the water seal
B. Apply sterile gauze to the insertion site
C. Place tape around the insertion site
D. Assess the client's respiratory status - ANSWER:B
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following
are expected findings? (Select all that apply)
A. Continuous bubbling in the water seal chamber
B. Gentle constant bubbling in the suction control chamber
C. Rise and fall in the level of water in the water seal chamber with inspiration
D. Exposed sutures without dressing
E. Drainage system upright at chest level - ANSWER:B, C
A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicate that
the drainage system is functioning properly
A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse
instruct the client to do?
A. Lie on his left side
B. Use the incentive spirometer
,C. Cough at regular intervals
D. Perform the Valsalva maneuver - ANSWER:D
A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of
the following should be included in the plan of care? (Select all that apply)
A. Encourage the client to cough every 2 hours
B Check for continuous bubbling in the suction chamber
C. Strip the drainage tubing every 4 hours
D. Clamp the tube once a day
E. Obtain a chest x ray - ANSWER:A, B, E
A nurse is assessing a client who has experienced a gun shot wound. Findings include BP 108/55, HR
124/min, RR 36/min, temperature 38.6 (101.4), and SaO2 95% on oxygen 15L/min via non-rebreather
mask. The client reports dyspnea and pain. The nurse reassess the client 30 minutes later. Which of the
following should the nurse report to the provider? (Select all that apply)
A. Distended neck veins
B. Tracheal deviation
C. Headache
D. Nausea
E. HR 154/min - ANSWER:A, B, E
An increased HR is due to impaired cardiac output as a result of trauma
A nurse is reviewing the prescriptions for a client who has pneumothorax. Which of the following actions
should the nurse perform first?
A. Assess the client's pain
B. Obtain a large-bore IV needle for decompression
C. Administer lorazepam (Ativan)
D. Prepare for chest tube insertion - ANSWER:B
A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the
following should be included in the teaching?
A. notify your provider if you experience weakness
B. You should be able to return to work in 1 week
C. You need to wear a mask when in crowded areas
D. Notify your provider if you experience a cough - ANSWER:D
, A nurse in the emergency department is assessing a client with a suspected flail chest. Which of the
following clinical findings confirm this diagnosis? (Select all that apply)
A. Bradycardia
B. Cyanosis
C. Hypotension
D. Dyspnea
E. Paradoxic chest movement - ANSWER:B, C, D, E
A nurse is orienting a newly licensed nurse who is caring for a client that is receiving mechanical
ventilation, which has been placed on pressure support ventilation (PSV) mode. Which of the following
statements by the newly licensed nurse demonstrates an understanding of PSV?
A. It keep the alveoli open and prevents atelectasis
B. It permits spontaneous ventilation to decrease the work of breathing
C. It is used with clients who have difficulty weaning from the ventilator
D. It delivers a preset ventilatory rate and tidal volume to the client - ANSWER:B
A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early
clinical manifestations of hypoxemia? (Select all that apply)
A. Confusion
B. Pale skin
C. Bradycardia
D. Hypotension
E. Elevated blood pressure - ANSWER:B, E
A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving
mechanical ventilation via a endotracheal tube. Which of the following should the nurse include in the
teaching?
A. Apply a vest restraint if self-extubation is attempted
B. Monitor ventilator settings every 8 hours
C. Document tube placement in centimeters at the angle of jaw
D. Assess breath sounds every 1 to 2 hours - ANSWER:D
A nurse is caring for a client who has dyspnea and is to receive oxygen continuously. Which of the
following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?
A. Nonrebreather mask
