1 | Page
GNRS 555: Exam 2 Review Questions
and Answers Latest Version
The home health nurse is assigned to visit these clients
when a change in agency staffing requires that one of the
clients be rescheduled for a visit on the following day.
Which client will be best to reschedule?
1. Client with emphysema who has been on home oxygen
for a month and has SpO2 levels of 91% to 93%
2. Client with history of a cough, weight loss, and night
sweats who has just had a positive Mantoux test
3. Client with newly diagnosed pleural effusion who
needs an admission visit and an initial intake assessment
4. Client with percutaneous lung biopsy yesterday who
called in to report increased dyspnea Ans: 1. Client with
emphysema who has been on home oxygen for a month
and has SpO2 levels of 91% to 93%
Rationale: The best client for the nurse to reschedule for
a home visit is the client with chronic emphysema who is
on home oxygen and who has an appropriate SpO2 level.
A SpO2 level of between 89% and 92% is appropriate and
satisfactory.The client with a positive Mantoux test, in
addition to a history of cough, weight loss, and night
sweats, is highly suspicious for tuberculosis and needs to
be seen that day. The nurse needs to perform follow-up
© 2025 All rights reserved
, 2 | Page
assessment and coordinate follow up testing. The nurse
may need to provide reporting to the public health
department and to develop a plan for close personal
contacts. A client with a newly diagnosed pleural effusion
needs a complete and thorough admission and intake
assessment to ensure that oxygenation and underlying
needs are addressed. A percutaneous lung biopsy may be
performed as an outpatient procedure. The client who
had a percutaneous lung biopsy and is experiencing
increased dyspnea needs to be assessed that day to
determine whether a life-threatening pneumothorax or
hemothorax has developed.
A client is admitted to the medical floor with a new
diagnosis of lung cancer. How will the nurse initially
assist the client in managing the anxiety associated with
the new diagnosis?
1. Encourage the client to ask questions and verbalize
concerns.
2. Provide privacy for the client to be alone to deal with
his or her own feelings.
3. Medicate the client with diazepam for anxiety every 8
hours.
4. Provide journals about cancer treatment. Ans: 1.
Encourage the client to ask questions and verbalize
concerns.
Rationale: The best way for the nurse to initially assist
the client in managing anxiety related to a new diagnosis
© 2025 All rights reserved
, 3 | Page
of cancer is to encourage the client to ask questions and
voice concerns. The availability of the nurse to answer
questions and listen to the client's concerns will help to
decrease anxiety.The client may choose to be alone,
although this may be a maladaptive coping behavior.
Diazepam every 8 hours will reduce the client's anxiety
but not help to manage its cause such as fear of the
unknown or fear of death. It is more important to work
with the client to assist him or her in dealing with those
issues first. Knowledge about cancer diagnosis and
treatment may help relieve anxiety but the nurse must
first assess the client's needs as well as the plan of care.
When caring for a client who has just undergone
thoracentesis, which of these interventions does the
nurse perform first?
1. Encourage coughing and deep breathing.
2. Schedule an immediate chest x-ray.
3. Document the volume of removed fluid in the medical
record.
4. Set up a water seal drainage unit. Ans: 2. Schedule an
immediate chest x-ray.
Rationale: After thoracentesis, the nurse first makes sure
a chest x-ray is performed to rule out possible
pneumothorax and mediastinal shift (shift of central
thoracic structures toward one side).Coughing and deep
breathing is done to promote lung expansion as part of
the treatment for the underlying disorder. This can wait
© 2025 All rights reserved
, 4 | Page
until a chest x-ray is completed. The volume of fluid will
be recorded in the medical record, after the nurse
schedules the x-ray to ensure a pneumothorax did not
occur. Pigtail drain catheters may be left in place to a
waterseal drainage system, rather than performing
thoracentesis aspiration on a recurring basis, but this
action is not standard.
A client has returned to the medical surgical unit after a
bronchoscopy. Which nursing task is best for the charge
nurse to delegate to the experienced unlicensed assistive
personnel (UAP)?
1. Assess breath sounds.
2. Offer clear liquids when gag reflex returns.
3. Determine level of consciousness.
4. Monitor blood pressure and pulse. Ans: 4. Monitor
blood pressure and pulse.
Rationale: The best nursing task for the charge nurse to
delegate to the experienced unlicensed assistive
personnel (UAP) is monitoring blood pressure and pulse.
An experienced UAP would have experience in taking
client vital signs after procedures requiring conscious
sedation or anesthesia.Evaluating breath sounds, gag
reflex, and determining level of consciousness are
considered nursing assessments and require the skill and
knowledge of a higher-level provider or professional
nurse.
© 2025 All rights reserved
GNRS 555: Exam 2 Review Questions
and Answers Latest Version
The home health nurse is assigned to visit these clients
when a change in agency staffing requires that one of the
clients be rescheduled for a visit on the following day.
Which client will be best to reschedule?
1. Client with emphysema who has been on home oxygen
for a month and has SpO2 levels of 91% to 93%
2. Client with history of a cough, weight loss, and night
sweats who has just had a positive Mantoux test
3. Client with newly diagnosed pleural effusion who
needs an admission visit and an initial intake assessment
4. Client with percutaneous lung biopsy yesterday who
called in to report increased dyspnea Ans: 1. Client with
emphysema who has been on home oxygen for a month
and has SpO2 levels of 91% to 93%
Rationale: The best client for the nurse to reschedule for
a home visit is the client with chronic emphysema who is
on home oxygen and who has an appropriate SpO2 level.
A SpO2 level of between 89% and 92% is appropriate and
satisfactory.The client with a positive Mantoux test, in
addition to a history of cough, weight loss, and night
sweats, is highly suspicious for tuberculosis and needs to
be seen that day. The nurse needs to perform follow-up
© 2025 All rights reserved
, 2 | Page
assessment and coordinate follow up testing. The nurse
may need to provide reporting to the public health
department and to develop a plan for close personal
contacts. A client with a newly diagnosed pleural effusion
needs a complete and thorough admission and intake
assessment to ensure that oxygenation and underlying
needs are addressed. A percutaneous lung biopsy may be
performed as an outpatient procedure. The client who
had a percutaneous lung biopsy and is experiencing
increased dyspnea needs to be assessed that day to
determine whether a life-threatening pneumothorax or
hemothorax has developed.
A client is admitted to the medical floor with a new
diagnosis of lung cancer. How will the nurse initially
assist the client in managing the anxiety associated with
the new diagnosis?
1. Encourage the client to ask questions and verbalize
concerns.
2. Provide privacy for the client to be alone to deal with
his or her own feelings.
3. Medicate the client with diazepam for anxiety every 8
hours.
4. Provide journals about cancer treatment. Ans: 1.
Encourage the client to ask questions and verbalize
concerns.
Rationale: The best way for the nurse to initially assist
the client in managing anxiety related to a new diagnosis
© 2025 All rights reserved
, 3 | Page
of cancer is to encourage the client to ask questions and
voice concerns. The availability of the nurse to answer
questions and listen to the client's concerns will help to
decrease anxiety.The client may choose to be alone,
although this may be a maladaptive coping behavior.
Diazepam every 8 hours will reduce the client's anxiety
but not help to manage its cause such as fear of the
unknown or fear of death. It is more important to work
with the client to assist him or her in dealing with those
issues first. Knowledge about cancer diagnosis and
treatment may help relieve anxiety but the nurse must
first assess the client's needs as well as the plan of care.
When caring for a client who has just undergone
thoracentesis, which of these interventions does the
nurse perform first?
1. Encourage coughing and deep breathing.
2. Schedule an immediate chest x-ray.
3. Document the volume of removed fluid in the medical
record.
4. Set up a water seal drainage unit. Ans: 2. Schedule an
immediate chest x-ray.
Rationale: After thoracentesis, the nurse first makes sure
a chest x-ray is performed to rule out possible
pneumothorax and mediastinal shift (shift of central
thoracic structures toward one side).Coughing and deep
breathing is done to promote lung expansion as part of
the treatment for the underlying disorder. This can wait
© 2025 All rights reserved
, 4 | Page
until a chest x-ray is completed. The volume of fluid will
be recorded in the medical record, after the nurse
schedules the x-ray to ensure a pneumothorax did not
occur. Pigtail drain catheters may be left in place to a
waterseal drainage system, rather than performing
thoracentesis aspiration on a recurring basis, but this
action is not standard.
A client has returned to the medical surgical unit after a
bronchoscopy. Which nursing task is best for the charge
nurse to delegate to the experienced unlicensed assistive
personnel (UAP)?
1. Assess breath sounds.
2. Offer clear liquids when gag reflex returns.
3. Determine level of consciousness.
4. Monitor blood pressure and pulse. Ans: 4. Monitor
blood pressure and pulse.
Rationale: The best nursing task for the charge nurse to
delegate to the experienced unlicensed assistive
personnel (UAP) is monitoring blood pressure and pulse.
An experienced UAP would have experience in taking
client vital signs after procedures requiring conscious
sedation or anesthesia.Evaluating breath sounds, gag
reflex, and determining level of consciousness are
considered nursing assessments and require the skill and
knowledge of a higher-level provider or professional
nurse.
© 2025 All rights reserved
