NUR 170 EXAM 2 WITH ACTUAL
CORRECT QUESTIONS AND
VERIFIED DETAILED ANSWERS
ALREADY GRADED A+
GUARANTEED ANSWERS
When caring for a client who has just undergone thoracentesis, which of these interventions does the
nurse perform first?
Schedule an immediate chest x-ray.
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)?
Monitor blood pressure and pulse.
The nurse is preparing the client for a diagnostic bronchoscopy. Which nursing intervention is essential
for the nurse to perform prior to the procedure?
Ensure the client has had nothing by mouth.
The RN has received report about four clients. Which client needs the most immediate assessment?
Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
Which assessment finding in the client with exacerbation of emphysema requires intervention by the
nurse?
Bronchial breath sounds heard at the bases
A client with asthma reports shortness of breath. Which of these findings does the nurse anticipate
when assessing this client's chest?
Expiratory wheezing not cleared by coughing
The RN and the LPN/LVN are working together to provide care for a group of clients on a medical
surgical unit. Which of these actions is most appropriate for the RN to perform?
Plan client and family teaching regarding upcoming pulmonary function testing.
,The nurse is assessing a client with chronic bronchitis who smoked 3 packs of cigarettes daily for 32
years. How does the nurse document pack-year history of smoking in the medical record?
Client has a 96 pack-year history
The nurse is caring for a client with heart failure and acute kidney injury. For which of these breath
sounds will the nurse assess?
Crackles
The nurse in the outpatient clinic is scheduling a client for pulmonary function tests. When teaching the
client about pulmonary function testing (PFT), which point is essential for the nurse to emphasize?
Ensure the client does not smoke for 6 hours before the test.
The nurse in a life care community for geriatric clients is providing education to a group of residents on
expected changes during aging. Which of these activities does the nurse encourage the older adult to
perform to maintain respiratory function?
Walk as tolerated each day.
A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after
having a knee replacement. What primary assessment will the nurse make while preparing the client for
a computed tomography (CT) scan?
"Are you allergic to iodine or shellfish?"
The nurse is caring for four clients who came to the emergency department with a productive cough.
Which of these clients requires immediate intervention by the nurse?
The client with pink, frothy sputum
Which client does the charge nurse on the medical-surgical unit assign to an RN who has floated from
the postanesthesia care unit (PACU)?
Client who had 1200 mL of pleural fluid removed by thoracentesis
The nurse is providing education on preventing pulmonary disorders at a community health fair. Which
of these groups does the nurse target?
Bakers
Coal miners
Furniture refinishers
Potters
The emergency department nurse is assessing a client who believes he has sustained a pneumothorax
after an outpatient thoracentesis earlier today. For which of these symptoms will the nurse assess?
Sensation of air hunger
Tracheal deviation
Blue discoloration of the lips
,The nurse is preparing a client with possible pulmonary embolism for a CT scan with contrast. Prior to
the scan, which of these assessment questions is essential for the nurse to ask?
"Did you take metformin today?"
The nurse is caring for a client who just returned from an open lung biopsy and has a prescription for
morphine by client controlled analgesia (PCA). Which of these actions to detect early opioid induced
respiratory depression does the nurse recommend?
Continuous capnography
The nurse is working in an urgent care clinic where four clients are waiting to be seen. Which client
needs to be evaluated first by the nurse?
Client who is speaking in three-word sentences and has an SpO2 of 90%
The nurse in the medical clinic is performing an assessment on an older adult client. Which finding
requires further assessment by the nurse?
Inability to state name and date of birth
The nurse is planning to provide tracheostomy care for a client with a soiled tracheostomy dressing.
Which of these actions would be included in the plan of care?
Suction the client if needed.
Cleanse the inner cannula with a mixture of peroxide and saline.
Replace the dressing with a sterile, folded 4 × 4 gauze.
A client has just been admitted to the emergency department and requires high-flow oxygen therapy
after suffering facial burns and smoke inhalation. Which oxygen delivery device will the nurse select?
Face tent
The respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator
alarms indicate high peak pressures. The ventilator tubing is clear. What is the best immediate action by
the nurse?
Suction the tracheostomy tube
A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has
completely dislodged both the inner cannula and the tracheostomy tube. Which action should the nurse
take first?
Direct someone to call the Rapid Response Team (RRT) while using a resuscitation bag and facemask.
A client with respiratory failure has been intubated and placed on a ventilator with 100% oxygen
delivery to maintain adequate saturation. Twenty-four hours later, the nurse notes new-onset crackles
, and decreased breath sounds. The most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm
Hg. What action will the nurse take next?
Collaborate with the provider to lower the FiO2 level.
The nurse is caring for a group of clients on a medical surgical unit. Which client will the nurse assess
first?
A client admitted 2 hours ago who has a 90 pack-year smoking history and is receiving 50% oxygen by
Venturi mask
A client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck."
What is the nurse's best response?
"Do you have a light scarf that you could place over it?"
A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy
procedure. Which nursing action must be taken first?
Auscultate lung sounds.
A client with pneumonia is receiving 100% oxygen via a non-rebreather mask. Which of these situations
requires immediate intervention by the nurse?
The oxygen reservoir deflates during inspiration.
A client is being discharged home with a tracheostomy. Which statement by the client indicates the
need for further teaching about correct tracheostomy care?
"I can only take baths, but no showers."
"I can put normal saline in my tracheostomy to keep the secretions from getting thick."
"I should put cotton or foam over the tracheostomy hole."
"I will be unable to wear a necklace."
The nurse is caring for a client who has had a tracheostomy placed yesterday. Which of these
assessments is essential for the nurse to make?
Assess for tachypnea.
The nurse is caring for a client with COPD who has a prescription for supplemental oxygen. Which
situation will cause the nurse to further assess the need to increase the fraction of inspired oxygen
(FiO2)?
Client has developed restlessness over the last hour
The nurse on a pulmonary unit is caring for a client who has had a tracheostomy placed earlier today.
Which of these techniques representing best practice will use the nurse use when suctioning the client's
tracheostomy tube?
Hyperoxygenate before and after suctioning.
CORRECT QUESTIONS AND
VERIFIED DETAILED ANSWERS
ALREADY GRADED A+
GUARANTEED ANSWERS
When caring for a client who has just undergone thoracentesis, which of these interventions does the
nurse perform first?
Schedule an immediate chest x-ray.
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)?
Monitor blood pressure and pulse.
The nurse is preparing the client for a diagnostic bronchoscopy. Which nursing intervention is essential
for the nurse to perform prior to the procedure?
Ensure the client has had nothing by mouth.
The RN has received report about four clients. Which client needs the most immediate assessment?
Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
Which assessment finding in the client with exacerbation of emphysema requires intervention by the
nurse?
Bronchial breath sounds heard at the bases
A client with asthma reports shortness of breath. Which of these findings does the nurse anticipate
when assessing this client's chest?
Expiratory wheezing not cleared by coughing
The RN and the LPN/LVN are working together to provide care for a group of clients on a medical
surgical unit. Which of these actions is most appropriate for the RN to perform?
Plan client and family teaching regarding upcoming pulmonary function testing.
,The nurse is assessing a client with chronic bronchitis who smoked 3 packs of cigarettes daily for 32
years. How does the nurse document pack-year history of smoking in the medical record?
Client has a 96 pack-year history
The nurse is caring for a client with heart failure and acute kidney injury. For which of these breath
sounds will the nurse assess?
Crackles
The nurse in the outpatient clinic is scheduling a client for pulmonary function tests. When teaching the
client about pulmonary function testing (PFT), which point is essential for the nurse to emphasize?
Ensure the client does not smoke for 6 hours before the test.
The nurse in a life care community for geriatric clients is providing education to a group of residents on
expected changes during aging. Which of these activities does the nurse encourage the older adult to
perform to maintain respiratory function?
Walk as tolerated each day.
A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after
having a knee replacement. What primary assessment will the nurse make while preparing the client for
a computed tomography (CT) scan?
"Are you allergic to iodine or shellfish?"
The nurse is caring for four clients who came to the emergency department with a productive cough.
Which of these clients requires immediate intervention by the nurse?
The client with pink, frothy sputum
Which client does the charge nurse on the medical-surgical unit assign to an RN who has floated from
the postanesthesia care unit (PACU)?
Client who had 1200 mL of pleural fluid removed by thoracentesis
The nurse is providing education on preventing pulmonary disorders at a community health fair. Which
of these groups does the nurse target?
Bakers
Coal miners
Furniture refinishers
Potters
The emergency department nurse is assessing a client who believes he has sustained a pneumothorax
after an outpatient thoracentesis earlier today. For which of these symptoms will the nurse assess?
Sensation of air hunger
Tracheal deviation
Blue discoloration of the lips
,The nurse is preparing a client with possible pulmonary embolism for a CT scan with contrast. Prior to
the scan, which of these assessment questions is essential for the nurse to ask?
"Did you take metformin today?"
The nurse is caring for a client who just returned from an open lung biopsy and has a prescription for
morphine by client controlled analgesia (PCA). Which of these actions to detect early opioid induced
respiratory depression does the nurse recommend?
Continuous capnography
The nurse is working in an urgent care clinic where four clients are waiting to be seen. Which client
needs to be evaluated first by the nurse?
Client who is speaking in three-word sentences and has an SpO2 of 90%
The nurse in the medical clinic is performing an assessment on an older adult client. Which finding
requires further assessment by the nurse?
Inability to state name and date of birth
The nurse is planning to provide tracheostomy care for a client with a soiled tracheostomy dressing.
Which of these actions would be included in the plan of care?
Suction the client if needed.
Cleanse the inner cannula with a mixture of peroxide and saline.
Replace the dressing with a sterile, folded 4 × 4 gauze.
A client has just been admitted to the emergency department and requires high-flow oxygen therapy
after suffering facial burns and smoke inhalation. Which oxygen delivery device will the nurse select?
Face tent
The respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator
alarms indicate high peak pressures. The ventilator tubing is clear. What is the best immediate action by
the nurse?
Suction the tracheostomy tube
A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has
completely dislodged both the inner cannula and the tracheostomy tube. Which action should the nurse
take first?
Direct someone to call the Rapid Response Team (RRT) while using a resuscitation bag and facemask.
A client with respiratory failure has been intubated and placed on a ventilator with 100% oxygen
delivery to maintain adequate saturation. Twenty-four hours later, the nurse notes new-onset crackles
, and decreased breath sounds. The most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm
Hg. What action will the nurse take next?
Collaborate with the provider to lower the FiO2 level.
The nurse is caring for a group of clients on a medical surgical unit. Which client will the nurse assess
first?
A client admitted 2 hours ago who has a 90 pack-year smoking history and is receiving 50% oxygen by
Venturi mask
A client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck."
What is the nurse's best response?
"Do you have a light scarf that you could place over it?"
A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy
procedure. Which nursing action must be taken first?
Auscultate lung sounds.
A client with pneumonia is receiving 100% oxygen via a non-rebreather mask. Which of these situations
requires immediate intervention by the nurse?
The oxygen reservoir deflates during inspiration.
A client is being discharged home with a tracheostomy. Which statement by the client indicates the
need for further teaching about correct tracheostomy care?
"I can only take baths, but no showers."
"I can put normal saline in my tracheostomy to keep the secretions from getting thick."
"I should put cotton or foam over the tracheostomy hole."
"I will be unable to wear a necklace."
The nurse is caring for a client who has had a tracheostomy placed yesterday. Which of these
assessments is essential for the nurse to make?
Assess for tachypnea.
The nurse is caring for a client with COPD who has a prescription for supplemental oxygen. Which
situation will cause the nurse to further assess the need to increase the fraction of inspired oxygen
(FiO2)?
Client has developed restlessness over the last hour
The nurse on a pulmonary unit is caring for a client who has had a tracheostomy placed earlier today.
Which of these techniques representing best practice will use the nurse use when suctioning the client's
tracheostomy tube?
Hyperoxygenate before and after suctioning.
