MED SURG TEST 4: CHAP. 28, 29, 31, 53,
54, 55 QUESTIONS AND CORRECT
ANSWERS VERIFIED LATEST 2023-2024
GRADE A +
A nursing student caring for a client removes the clients
oxygen as prescribed. The client is now breathing
what percentage of oxygen in the room air?
a. 14%
b. 21%
c. 28%
d. 31% - CORRECT ANSWER >>ANS: B
Room air is 21% oxygen.
A client is scheduled to have a tracheostomy placed in an
hour. What action by the nurse is the priority?
a. Administer prescribed anxiolytic medication.
b. Ensure informed consent is on the chart.
c. Reinforce any teaching done previously.
d. Start the preoperative antibiotic infusion. - CORRECT
ANSWER >>ANS: B
Since this is an operative procedure, the client must sign
an informed consent, which must be on the chart. Giving
anxiolytics and antibiotics and reinforcing teaching may
also be required but do not take priority
,A client has a tracheostomy that is 3 days old. Upon
assessment, the nurse notes the clients face is puffy and
the eyelids are swollen. What action by the nurse takes
priority?
a. Assess the clients 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. - CORRECT
ANSWER >>ANS: A
This client may have subcutaneous emphysema, which is
air that leaks into the tissues surrounding the
tracheostomy. The nurse should first assess the clients
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 clients bed.
b. Measure and compare cuff pressures.
c. Place the client on NPO status.
,d. Request that the client have a swallow study -
CORRECT ANSWER >>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 should 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.
An unlicensed assistive personnel (UAP) was feeding a
client with a tracheostomy. Later that evening, the
UAP reports that the client had a coughing spell during the
meal. What action by the nurse takes priority?
a. Assess the clients lung sounds.
b. Assign a different UAP to the client.
c. Report the UAP to the manager.
d. Request thicker liquids for meals. - CORRECT
ANSWER >>ANS: A
The priority is to check the clients oxygenation because he
or she may have aspirated. Once the client has been
assessed, the nurse can consult with the registered
dietitian about appropriately thickened liquids. The UAP
, should have reported the incident immediately, but
addressing that issue is not the immediate priority.
A student nurse is providing tracheostomy care. What
action by the student requires intervention by the
instructor?
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 - CORRECT
ANSWER >>ANS: C
To prevent pressure ulcers and for client safety, when ties
are used that must be knotted, the knot should be
placed at the side of the clients neck, not in back. The
other actions are appropriate.
A student is practicing suctioning a tracheostomy in the
skills laboratory. What action by the student
demonstrates that more teaching is needed?
a. Applying suction while inserting the catheter
b. Preoxygenating the client prior to suctioning
c. Suctioning for a total of three times if needed
d. Suctioning for only 10 to 15 seconds each time -
CORRECT ANSWER >>ANS: A
Suction should only be applied while withdrawing the
catheter. The other actions are appropriate.
54, 55 QUESTIONS AND CORRECT
ANSWERS VERIFIED LATEST 2023-2024
GRADE A +
A nursing student caring for a client removes the clients
oxygen as prescribed. The client is now breathing
what percentage of oxygen in the room air?
a. 14%
b. 21%
c. 28%
d. 31% - CORRECT ANSWER >>ANS: B
Room air is 21% oxygen.
A client is scheduled to have a tracheostomy placed in an
hour. What action by the nurse is the priority?
a. Administer prescribed anxiolytic medication.
b. Ensure informed consent is on the chart.
c. Reinforce any teaching done previously.
d. Start the preoperative antibiotic infusion. - CORRECT
ANSWER >>ANS: B
Since this is an operative procedure, the client must sign
an informed consent, which must be on the chart. Giving
anxiolytics and antibiotics and reinforcing teaching may
also be required but do not take priority
,A client has a tracheostomy that is 3 days old. Upon
assessment, the nurse notes the clients face is puffy and
the eyelids are swollen. What action by the nurse takes
priority?
a. Assess the clients 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. - CORRECT
ANSWER >>ANS: A
This client may have subcutaneous emphysema, which is
air that leaks into the tissues surrounding the
tracheostomy. The nurse should first assess the clients
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 clients bed.
b. Measure and compare cuff pressures.
c. Place the client on NPO status.
,d. Request that the client have a swallow study -
CORRECT ANSWER >>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 should 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.
An unlicensed assistive personnel (UAP) was feeding a
client with a tracheostomy. Later that evening, the
UAP reports that the client had a coughing spell during the
meal. What action by the nurse takes priority?
a. Assess the clients lung sounds.
b. Assign a different UAP to the client.
c. Report the UAP to the manager.
d. Request thicker liquids for meals. - CORRECT
ANSWER >>ANS: A
The priority is to check the clients oxygenation because he
or she may have aspirated. Once the client has been
assessed, the nurse can consult with the registered
dietitian about appropriately thickened liquids. The UAP
, should have reported the incident immediately, but
addressing that issue is not the immediate priority.
A student nurse is providing tracheostomy care. What
action by the student requires intervention by the
instructor?
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 - CORRECT
ANSWER >>ANS: C
To prevent pressure ulcers and for client safety, when ties
are used that must be knotted, the knot should be
placed at the side of the clients neck, not in back. The
other actions are appropriate.
A student is practicing suctioning a tracheostomy in the
skills laboratory. What action by the student
demonstrates that more teaching is needed?
a. Applying suction while inserting the catheter
b. Preoxygenating the client prior to suctioning
c. Suctioning for a total of three times if needed
d. Suctioning for only 10 to 15 seconds each time -
CORRECT ANSWER >>ANS: A
Suction should only be applied while withdrawing the
catheter. The other actions are appropriate.
