NURS 251 ATI PROCTORED
A nurse is suctioning a client's airway using in-line suctioning. Which of the following actions
should the nurse plan to take?
1) Hyperoxygenate the client before disconnecting the ventilator
2) Apply suction pressure while advancing the catheter
3) Wear a face shield during the procedure
4) Reuse the catheter repeatedly - ANS 4) Reuse the catheter repeatedly
---> with in-line suctioning, the catheter attaches to the ventilator tubing and does not need to be
replaced until the system is replaced. It can be used repeatedly
A nurse is preparing to suction a client's tracheostomy. Which of the following actions should the
nurse take?
1) Suction for 30 seconds with each pass
2) allow 2 min in between suctioning to reoxygenate the lungs
3) Use a rotating motion when inserting the catheter from the trach
4) Set the suction pressure to 180 mmHg - ANS 2) Allow 2 min in between suctioning to
reoxygenate the lungs
---> allow the client to cough and deep breathe and allow the lungs to reoxygenate
a nurse is preparing to suction a client's oral airway. Which of the following devices or methods
should the nurse use?
1) in-line suctioning
2) Yankauer catheter
3) Bulb syringe
4) Open suctioning - ANS Yankauer Catheter
---> helps clear secretions from the mouth. This is the appropriate device to use for clients who
can cough effectively but cannot swallow or expectorate secretions
A nurse is caring for a client who has a trach tube with an inner cannula in place. Which of the
following supplies should the nurse use to dry the inner cannula of the client's trach tube after
cleaning it?
1) Paper towels
2) cotton-tipped applicators
3) Folded pipe cleaners
4) Facial tissues - ANS Folded pipe cleaners
---> they remain intact without leaving any particulate matter the client could aspirate
A nurse is caring for a client who sustained trauma to their head and neck and will require
long-term airway support. Which of the following pieces of equipment will be required for home
health care for this client?
,1) Nasopharyngeal airway device
2) Oropharyngeal airway device
3) Endotracheal tube
4) Trach Tube - ANS Trach Tube
A nurse is performing chest physiotherapy for a client who needs help mobilizing and
expectorating thick pulmonary secretions. To increase the turbulence of the air the client
exhales, the nurse should use which of the following techniques?
1) Vibration
2) Percussion
3) Nebulization
4) Postural Drainage - ANS Vibration
---> used during or after percussion to increase the turbulence of exhaled air and loosen
secretions
A nurse is caring for a client who has a trach tube in place. During trach care, which of the
following should the nurse place underneath the flange of the outer cannula?
1) Commercially prepared transparent dressing
2) Cotton-filled gauze square
3) Commercially prepared fenestrated dressing
4) Twill tape - ANS Commercially prepared fenestrated dressing
---> made of material that does not unravel and has a fenestration slit designed to fit around the
trach tube under flanges
A nurse is caring for a client who has a cuffed endotracheal tube in place. Which of the following
actions should the nurse plan to take?
1) Repositioning the ET tube in the client's mouth every 12 hr
2) providing oral care every 24 hour
3) Applying the securing tape over the client's ears
4) Maintaining a cuff pressure of 35 mmHg - ANS Repositioning the ET tube in the client's
mouth every 12 hr
---> helps prevent irritation to the oral mucous membranes
A nurse started a transfusion of packed RBCs for a client 1 hr ago. The client has suddenly
developed shaking chills, muscle stiffness, and a temperature of 101.5 F. The client appears
flushed and reports a headache and "nervousness". The nurse should identify that the client has
most likely developed which of the following types of transfusion reaction?
1) Septic
2) Acute hemolytic
3) allergic
4) Febrile nonhemolytic - ANS Febrile nonhemolytic
---> fever usually develops within 2 hrs after the transfusion has started. Other classic
symptoms include chills, headache, flushing, anxiety, and muscle pain
, A platelet transfusion is indicated for a patient who
1) has a systemic infection
2) has thrombocytopenia
3) is in hypovolemic shock
4) has hemolytic anemia - ANS Has thrombocytopenia
---> low platelet count (drops below 20,000)
A nurse is providing education to a client who has a prescription for a blood transfusion. Which
of the following statements should the nurse include in the teaching?
1) "I will check your vitals every 15 min throughout the blood transfusion"
2) "I might have a nursing assistant check on you periodically during transfusion"
3) "If you have no adverse effects in the first 15-30 min, you will not have any adverse effects
later"
4) "You must immediately report any symptoms like chills, nausea, or itching" - ANS You must
immediately report any symptoms like chills, nausea, or itching
A nurse is preparing a blood transfusion for a client who has type A blood. The nurse should
know that the client can safely receive blood from blood group O because
1) type O blood contains no A antigens
2) Type A blood contains O antibodies
3) Type O blood contains no A antibodies
4) type A blood contains NO antigens - ANS Type O blood contains no A antigens
A nurse is preparing to initiate the transfusion of a unit of packed RBCs to a client. After the unit
of blood has arrived, which of the following procedures will help the nurse protect the client
against the possibility of a blood-group incompatibility?
1) Comparing the ID numbers on the blood unit with those on the order form and the client's
wrist band
2) Obtaining a blood sample from the client for typing and crossmatching
3) Giving a prescribed pre-med 30 min prior to starting the transfusion
4) observing the client 15-30 min after the transfusion is initiated - ANS Comparing the ID
numbers on the blood unit with those on the order form and the client's wrist band
When administering a transfusion of packed red blood cells, it is important to
1) allow the blood to warm to room temp for 1 hr
2) make sure the entire unit is transfused within 4 hr
3) begin the blood transfusion at a rate of 10 mL/hr
4) change the blood tubing after every unit infused - ANS make sure the entire is transfused
within 4 hr
A nurse is caring for a client who is receiving a blood transfusion and reports itching. The nurse
observes areas of urticaria on the client's skin. Which of the following actions should the nurse
take?
1) Administer prescribed antipyretic
A nurse is suctioning a client's airway using in-line suctioning. Which of the following actions
should the nurse plan to take?
1) Hyperoxygenate the client before disconnecting the ventilator
2) Apply suction pressure while advancing the catheter
3) Wear a face shield during the procedure
4) Reuse the catheter repeatedly - ANS 4) Reuse the catheter repeatedly
---> with in-line suctioning, the catheter attaches to the ventilator tubing and does not need to be
replaced until the system is replaced. It can be used repeatedly
A nurse is preparing to suction a client's tracheostomy. Which of the following actions should the
nurse take?
1) Suction for 30 seconds with each pass
2) allow 2 min in between suctioning to reoxygenate the lungs
3) Use a rotating motion when inserting the catheter from the trach
4) Set the suction pressure to 180 mmHg - ANS 2) Allow 2 min in between suctioning to
reoxygenate the lungs
---> allow the client to cough and deep breathe and allow the lungs to reoxygenate
a nurse is preparing to suction a client's oral airway. Which of the following devices or methods
should the nurse use?
1) in-line suctioning
2) Yankauer catheter
3) Bulb syringe
4) Open suctioning - ANS Yankauer Catheter
---> helps clear secretions from the mouth. This is the appropriate device to use for clients who
can cough effectively but cannot swallow or expectorate secretions
A nurse is caring for a client who has a trach tube with an inner cannula in place. Which of the
following supplies should the nurse use to dry the inner cannula of the client's trach tube after
cleaning it?
1) Paper towels
2) cotton-tipped applicators
3) Folded pipe cleaners
4) Facial tissues - ANS Folded pipe cleaners
---> they remain intact without leaving any particulate matter the client could aspirate
A nurse is caring for a client who sustained trauma to their head and neck and will require
long-term airway support. Which of the following pieces of equipment will be required for home
health care for this client?
,1) Nasopharyngeal airway device
2) Oropharyngeal airway device
3) Endotracheal tube
4) Trach Tube - ANS Trach Tube
A nurse is performing chest physiotherapy for a client who needs help mobilizing and
expectorating thick pulmonary secretions. To increase the turbulence of the air the client
exhales, the nurse should use which of the following techniques?
1) Vibration
2) Percussion
3) Nebulization
4) Postural Drainage - ANS Vibration
---> used during or after percussion to increase the turbulence of exhaled air and loosen
secretions
A nurse is caring for a client who has a trach tube in place. During trach care, which of the
following should the nurse place underneath the flange of the outer cannula?
1) Commercially prepared transparent dressing
2) Cotton-filled gauze square
3) Commercially prepared fenestrated dressing
4) Twill tape - ANS Commercially prepared fenestrated dressing
---> made of material that does not unravel and has a fenestration slit designed to fit around the
trach tube under flanges
A nurse is caring for a client who has a cuffed endotracheal tube in place. Which of the following
actions should the nurse plan to take?
1) Repositioning the ET tube in the client's mouth every 12 hr
2) providing oral care every 24 hour
3) Applying the securing tape over the client's ears
4) Maintaining a cuff pressure of 35 mmHg - ANS Repositioning the ET tube in the client's
mouth every 12 hr
---> helps prevent irritation to the oral mucous membranes
A nurse started a transfusion of packed RBCs for a client 1 hr ago. The client has suddenly
developed shaking chills, muscle stiffness, and a temperature of 101.5 F. The client appears
flushed and reports a headache and "nervousness". The nurse should identify that the client has
most likely developed which of the following types of transfusion reaction?
1) Septic
2) Acute hemolytic
3) allergic
4) Febrile nonhemolytic - ANS Febrile nonhemolytic
---> fever usually develops within 2 hrs after the transfusion has started. Other classic
symptoms include chills, headache, flushing, anxiety, and muscle pain
, A platelet transfusion is indicated for a patient who
1) has a systemic infection
2) has thrombocytopenia
3) is in hypovolemic shock
4) has hemolytic anemia - ANS Has thrombocytopenia
---> low platelet count (drops below 20,000)
A nurse is providing education to a client who has a prescription for a blood transfusion. Which
of the following statements should the nurse include in the teaching?
1) "I will check your vitals every 15 min throughout the blood transfusion"
2) "I might have a nursing assistant check on you periodically during transfusion"
3) "If you have no adverse effects in the first 15-30 min, you will not have any adverse effects
later"
4) "You must immediately report any symptoms like chills, nausea, or itching" - ANS You must
immediately report any symptoms like chills, nausea, or itching
A nurse is preparing a blood transfusion for a client who has type A blood. The nurse should
know that the client can safely receive blood from blood group O because
1) type O blood contains no A antigens
2) Type A blood contains O antibodies
3) Type O blood contains no A antibodies
4) type A blood contains NO antigens - ANS Type O blood contains no A antigens
A nurse is preparing to initiate the transfusion of a unit of packed RBCs to a client. After the unit
of blood has arrived, which of the following procedures will help the nurse protect the client
against the possibility of a blood-group incompatibility?
1) Comparing the ID numbers on the blood unit with those on the order form and the client's
wrist band
2) Obtaining a blood sample from the client for typing and crossmatching
3) Giving a prescribed pre-med 30 min prior to starting the transfusion
4) observing the client 15-30 min after the transfusion is initiated - ANS Comparing the ID
numbers on the blood unit with those on the order form and the client's wrist band
When administering a transfusion of packed red blood cells, it is important to
1) allow the blood to warm to room temp for 1 hr
2) make sure the entire unit is transfused within 4 hr
3) begin the blood transfusion at a rate of 10 mL/hr
4) change the blood tubing after every unit infused - ANS make sure the entire is transfused
within 4 hr
A nurse is caring for a client who is receiving a blood transfusion and reports itching. The nurse
observes areas of urticaria on the client's skin. Which of the following actions should the nurse
take?
1) Administer prescribed antipyretic
