D220 WGU Exam 1 2024
a a a a a
a
1. aA anurse aobtains athe ahealth ahistory aof aa aclient awho ais arecently adiagnosed awith alung acancer
aand aidentifies athat athe aclient ahas aa a60pack-year a smoking ahistory. aWhich aaction ais amost
aimportant afor athe anurse ato atake awhen ainterviewing athis aclient? a
a. Tell athe aclient athat ahe aneeds ato aquit asmoking ato astop afurther acancer adevelopment. a
b. Encourage athe aclient ato abe acompletely ahonest aabout aboth atobacco aand amarijuana ause. ac.
aMaintain a a anonjudgmental aattitude ato aavoid acausing athe aclient ato afeel aguilty. a
d. aAvoid agiving athe aclient afalse ahope aregarding acancer atreatment aand aprognosis. a- aANS: aC
aSmoking ahistory aincludes athe ause aof acigarettes, a cigars, apipe atobacco, amarijuana, aand aother
acontrolled asubstances. aBecause athe a client amay ahave aguilt aor adenial a about athis ahabit, aassume
aa anonjudgmental aattitude aduring athe ainterview. aThis awill a encourage athe aclient ato abe ahonest
aabout athe aexposure. aAsk athe aclient awhether aany a of athese asubstances aare aused anow aor awere
aused ain athe apast. aAssess awhether athe aclient ahas a passive aexposure ato asmoke ain athe ahome aor
aworkplace. aIf athe aclient asmokes, aask afor ahow along, ahow amany apacks aper aday, aand awhether
ahe aor a she ahas aquit a smoking a(and ahow along aago). aDocument athe a smoking ahistory ain apack-
years a(number aof apacks asmoked adaily amultiplied aby athe anumber aof ayears athe aclient ahas
asmoked). aQuitting asmoking amay anot astop afurther acancer adevelopment. aThis astatement awould
abe agiving athe aclient afalse ahope, awhich a should abe aavoided, abut ais anot aas aimportant aas
amaintaining aa anonjudgmental aattitude. a
DIF: aApplying a
a
2. aA anurse aassesses aa aclient aafter aan aopen alung abiopsy. aWhich aassessment afinding ais amatched
awith athe acorrect aintervention? a
a. Client astates ahe ais adizzy. aNurse aapplies aoxygen aand apulse aoximetry. a
b. Clients aheart arate ais a55 abeatsmin. aNurse awithholds apain amedication. a
c. Client ahas areduced abreath asounds. aNurse acalls aphysician aimmediately. a
d. Clients arespiratory arate ais a18 abreaths amin. aNurse adecreases aoxygen aflow arate. a- aANS: aC aA
apotentially aserious acomplication aafter abiopsy ais a pneumothorax, awhich ais aindicated aby
adecreased aor aabsent abreath a sounds. aThe aphysician aneeds ato abe anotified aimmediately.
aDizziness aafter athe aprocedure ais anot aan aexpected afinding. aIf athe aclients aheart arate ais a55
abeats amin, ano areason ais aknown ato awithhold apain amedication. aA arespiratory arate aof a18
abreaths a
a
3. aA anurse aassesses aa aclients arespiratory astatus. aWhich ainformation ais aof ahighest apriority
afor athe anurse ato aobtain? aa. aAverage adaily afluid aintake ab. aNeck acircumference a
c. Height aand aweight a
d. Occupation aand ahobbies a- aANS: aD a
Many arespiratory aproblems aoccur aas aa aresult aof achronic aexposure ato ainhalation airritants aused
ain aa aclients aoccupation aand ahobbies. aAlthough ait awill abe aimportant afor athe anurse ato aassess
athe aclients afluid aintake, aheight, aand a weight, athese awill anot abe aas aimportant aas adetermining
ahis aoccupation aand ahobbies. aDetermining athe aclients aneck acircumference awill anot abe aan
aimportant apart aof aa arespiratory aassessment. a
,Test aBank a- aMedical-Surgical aNursing: aConcepts afor aInterprofessional aCollaborative aCare a9e
a214 a aDIF: aApplying a
a
4. aA anurse ais acaring afor aan aolder aadult aclient awho ahas aa apulmonary ainfection. aWhich aaction
ashould a
a
the anurse atake
afirst?
a
a. aEncourage athe aclient ato aincrease afluid
aintake.
a
b. aAssess athe aclients alevel aof
aconsciousness.
c. aRaise athe ahead aof athe abed ato aat aleast a45 adegrees. ad. aProvide athe aclient awith ahumidified
aoxygen. a-
a
ANS:
aB
Assessing athe aclients alevel aof aconsciousness awill abe amost aimportant abecause ait awill ashow ahow
athe a
client ais aresponding ato athe apresence aof athe ainfection. aAlthough ait awill abe aimportant afor athe
anurse ato a
a
encourage athe aclient ato aturn, acough, aand afrequently abreathe adeeply; araise athe ahead aof athe
abed;
increase aoral afluid aintake; aand ahumidify athe aoxygen aadministered, anone aof athese aactions awill
abe aas a
important aas aassessing athe alevel aof aconsciousness. aAlso, athe aclient awho ahas aa apulmonary
ainfection
a
may anot abe aable ato acough aeffectively aif aan aarea aof aabscess ais
apresent.
a
DIF:
aApplying
a
5. aA anurse ais aproviding acare aafter aauscultating aclients abreath asounds. aWhich aassessment
afinding ais a correctly amatched ato athe anurses aprimary aintervention? a
a. Hollow asounds aare aheard aover athe atrachea. aThe anurse aincreases athe aoxygen aflow arate. a
b. Crackles aare aheard ain abases. aThe anurse aencourages athe aclient ato acough aforcefully. a
c. Wheezes aare aheard ain acentral aareas. aThe anurse aadministers aan ainhaled abronchodilator. ad.
aVesicular asounds a are aheard aover athe aperiphery. a The anurse ahas athe a client abreathe adeeply. a-
aANS: aC aWheezes aare aindicative aof anarrowed aairways, aand abronchodilators ahelp ato aopen
athe aair apassages. a Hollow a sounds aare atypically aheard aover athe atrachea, aand ano aintervention
ais anecessary. aIf acrackles aare aheard, athe a client amay aneed aa adiuretic. aCrackles arepresent aa
adeep ainterstitial aprocess, aand acoughing aforcefully awill anot ahelp athe aclient aexpectorate
asecretions. aVesicular asounds aheard ain athe aperiphery aare anormal a and arequire ano
aintervention. a
DIF: aApplying a
a
,6. aA anurse aobserves athat aa aclients aanteroposterior a(AP) achest adiameter ais athe asame aas athe
alateral achest adiameter. a Which aquestion a should athe anurse aask athe aclient ain aresponse ato athis
afinding? aa. aAre ayou ataking aany amedications aor aherbal asupplements? a
b. Do ayou ahave aany achronic abreathing aproblems? a
c. How aoften ado ayou aperform aaerobic aexercise? a
d. What ais ayour aoccupation aand awhat aare ayour ahobbies? a- aANS: aB a
The anormal achest ahas aa alateral adiameter athat ais atwice aas alarge aas athe aAP adiameter. aWhen athe
aAP adiameter a approaches aor aexceeds athe alateral adiameter, athe aclient ais a said ato ahave aa abarrel
achest. a Most acommonly, abarrel achest aoccurs aas a a a result aof aa along-term achronic aairflow
alimitation aproblem, asuch a as achronic aobstructive a pulmonary adisease aor asevere achronic a asthma.
aIt acan a also abe aseen ain apeople a who ahave alived aat aa ahigh aaltitude afor amany ayears. aTherefore,
aan aAP achest adiameter athat ais athe asame a as athe alateral achest adiameter a should abe arechecked abut
ais anot aas aindicative aof aunderlying adisease aprocesses aas aan aAP adiameter athat aexceeds athe
alateral adiameter. a Medications, aherbal asupplements, aand a aerobic aexercise aare anot aassociated
awith aa abarrel achest. aAlthough aoccupation aand ahobbies amay aexpose a a aclient ato airritants athat
acan acause achronic alung adisorders aand abarrel achest, a
a
Test aBank a- aMedical-Surgical aNursing: aConcepts afor aInterprofessional aCollaborative aCare a9e
a215
a
aasking aabout achronic abreathing aproblems ais amore adirect aand a should abe a asked
afirst.
DIF: aApplying a
a
7. aA anurse ais aassessing aa aclient awho ais arecovering afrom aa alung abiopsy. aWhich aassessment
afinding a
a
requires aimmediate
aaction?
a
a. aIncreased a
atemperature
b. aAbsent abreath
asounds
a
c. aProductive
acough
a
d. aIncisional adiscomfort a- aANS:
aB
a
Absent abreath asounds amay aindicate athat athe aclient ahas aa apneumothorax, aa aserious
acomplication
a
after aa aneedle abiopsy aor aopen alung abiopsy. aThe aother amanifestations aare anot alife
athreatening.
a
DIF:
aApplying
a
8. aA anurse ais acaring afor aa aclient awho ais ascheduled ato aundergo aa athoracentesis. aWhich
aintervention ashould athe anurse acomplete aprior ato a the aprocedure? a
, a. Measure aoxygen asaturation abefore aand aafter aa a12-minute awalk. a
b. Verify athat athe aclient aunderstands aall apossible acomplications. a
c. Explain athe aprocedure ain adetail ato athe aclient aand athe afamily. a a
d. Validate athat ainformed aconsent ahas abeen agiven aby athe aclient. a- aANS: aD a
A athoracentesis ais aan ainvasive aprocedure awith amany apotentially aserious acomplications.
aVerifying athat athe aclient aunderstands acomplications aand aexplaining athe aprocedure ato abe
aperformed awill abe adone aby athe aphysician aor anurse apractitioner, anot athe anurse. aMeasurement
aof aoxygen a saturation abefore aand a after aa a12-minute awalk ais anot aa aprocedure aunique ato aa
athoracentesis. aDIF: a Applying a
a
9. aA anurse aassesses aa aclient aafter aa athoracentesis. aWhich aassessment afinding awarrants
aimmediate aaction? a a
a. The aclient arates apain aas aa a5-10 aat athe asite aof athe aprocedure. a
b. A asmall aamount aof adrainage afrom athe asite ais anoted. a
c. Pulse aoximetry ais a93% aon a2 aliters aof aoxygen. a
d. The atrachea ais adeviated atoward athe aopposite aside aof athe aneck. a- aANS: aD a
A adeviated atrachea ais aa amanifestation aof aa atension apneumothorax, awhich ais aa amedical
aemergency. aThe aother afindings aare anormal aor anear anormal. a
a
10. aA anurse acares afor aa aclient awho ahad aa abronchoscopy a2 ahours aago. aThe aclient aasks afor aa
adrink aof awater. aWhich aaction ashould athe anurse atake anext? a
a. Call athe aphysician aand arequest aa aprescription afor afood aand awater. a
b. Provide athe aclient awith aice achips ainstead aof aa adrink aof awater. a
c. Assess athe aclients agag areflex abefore agiving aany afood aor awater. a
d. Let athe aclient ahave aa asmall asip ato asee awhether ahe aor ashe acan aswallow. a- aANS: aC a
The atopical aanesthetic aused aduring athe aprocedure awill ahave aaffected athe aclients agag areflex.
aBefore aallowing athe aclient aanything ato aeat aor adrink, athe anurse amust acheck afor athe areturn aof
athis areflex. aDIF: aApplying a
a
11. aA anurse aplans acare afor aa aclient awho ais aexperiencing adyspnea aand amust astop amultiple
atimes awhen aclimbing aa aflight aof astairs. a Which aintervention ashould athe anurse ainclude ain athis
aclients aplan aof a care? a
a. Assistance awith aactivities aof adaily aliving a
b. Physical atherapy aactivities aevery aday a
c. Oxygen atherapy aat a2 aliters aper anasal acannula ad. aComplete abedrest awith afrequent
arepositioning a- a
ANS: aA a
A aclient awith adyspnea aand adifficulty acompleting aactivities asuch aas aclimbing aa aflight aof astairs
ahas aclass aIII adyspnea. aThe anurse a should aprovide aassistance awith a activities aof adaily aliving.
aThese aclients a should abe aencouraged ato aparticipate ain a activities aas atolerated. aThey a should anot
abe aon acomplete abedrest, amay anot abe aable ato atolerate adaily aphysical atherapy, aand aonly aneed
aoxygen aif ahypoxia ais apresent. a
DIF: aApplying a
a
a a a a a
a
1. aA anurse aobtains athe ahealth ahistory aof aa aclient awho ais arecently adiagnosed awith alung acancer
aand aidentifies athat athe aclient ahas aa a60pack-year a smoking ahistory. aWhich aaction ais amost
aimportant afor athe anurse ato atake awhen ainterviewing athis aclient? a
a. Tell athe aclient athat ahe aneeds ato aquit asmoking ato astop afurther acancer adevelopment. a
b. Encourage athe aclient ato abe acompletely ahonest aabout aboth atobacco aand amarijuana ause. ac.
aMaintain a a anonjudgmental aattitude ato aavoid acausing athe aclient ato afeel aguilty. a
d. aAvoid agiving athe aclient afalse ahope aregarding acancer atreatment aand aprognosis. a- aANS: aC
aSmoking ahistory aincludes athe ause aof acigarettes, a cigars, apipe atobacco, amarijuana, aand aother
acontrolled asubstances. aBecause athe a client amay ahave aguilt aor adenial a about athis ahabit, aassume
aa anonjudgmental aattitude aduring athe ainterview. aThis awill a encourage athe aclient ato abe ahonest
aabout athe aexposure. aAsk athe aclient awhether aany a of athese asubstances aare aused anow aor awere
aused ain athe apast. aAssess awhether athe aclient ahas a passive aexposure ato asmoke ain athe ahome aor
aworkplace. aIf athe aclient asmokes, aask afor ahow along, ahow amany apacks aper aday, aand awhether
ahe aor a she ahas aquit a smoking a(and ahow along aago). aDocument athe a smoking ahistory ain apack-
years a(number aof apacks asmoked adaily amultiplied aby athe anumber aof ayears athe aclient ahas
asmoked). aQuitting asmoking amay anot astop afurther acancer adevelopment. aThis astatement awould
abe agiving athe aclient afalse ahope, awhich a should abe aavoided, abut ais anot aas aimportant aas
amaintaining aa anonjudgmental aattitude. a
DIF: aApplying a
a
2. aA anurse aassesses aa aclient aafter aan aopen alung abiopsy. aWhich aassessment afinding ais amatched
awith athe acorrect aintervention? a
a. Client astates ahe ais adizzy. aNurse aapplies aoxygen aand apulse aoximetry. a
b. Clients aheart arate ais a55 abeatsmin. aNurse awithholds apain amedication. a
c. Client ahas areduced abreath asounds. aNurse acalls aphysician aimmediately. a
d. Clients arespiratory arate ais a18 abreaths amin. aNurse adecreases aoxygen aflow arate. a- aANS: aC aA
apotentially aserious acomplication aafter abiopsy ais a pneumothorax, awhich ais aindicated aby
adecreased aor aabsent abreath a sounds. aThe aphysician aneeds ato abe anotified aimmediately.
aDizziness aafter athe aprocedure ais anot aan aexpected afinding. aIf athe aclients aheart arate ais a55
abeats amin, ano areason ais aknown ato awithhold apain amedication. aA arespiratory arate aof a18
abreaths a
a
3. aA anurse aassesses aa aclients arespiratory astatus. aWhich ainformation ais aof ahighest apriority
afor athe anurse ato aobtain? aa. aAverage adaily afluid aintake ab. aNeck acircumference a
c. Height aand aweight a
d. Occupation aand ahobbies a- aANS: aD a
Many arespiratory aproblems aoccur aas aa aresult aof achronic aexposure ato ainhalation airritants aused
ain aa aclients aoccupation aand ahobbies. aAlthough ait awill abe aimportant afor athe anurse ato aassess
athe aclients afluid aintake, aheight, aand a weight, athese awill anot abe aas aimportant aas adetermining
ahis aoccupation aand ahobbies. aDetermining athe aclients aneck acircumference awill anot abe aan
aimportant apart aof aa arespiratory aassessment. a
,Test aBank a- aMedical-Surgical aNursing: aConcepts afor aInterprofessional aCollaborative aCare a9e
a214 a aDIF: aApplying a
a
4. aA anurse ais acaring afor aan aolder aadult aclient awho ahas aa apulmonary ainfection. aWhich aaction
ashould a
a
the anurse atake
afirst?
a
a. aEncourage athe aclient ato aincrease afluid
aintake.
a
b. aAssess athe aclients alevel aof
aconsciousness.
c. aRaise athe ahead aof athe abed ato aat aleast a45 adegrees. ad. aProvide athe aclient awith ahumidified
aoxygen. a-
a
ANS:
aB
Assessing athe aclients alevel aof aconsciousness awill abe amost aimportant abecause ait awill ashow ahow
athe a
client ais aresponding ato athe apresence aof athe ainfection. aAlthough ait awill abe aimportant afor athe
anurse ato a
a
encourage athe aclient ato aturn, acough, aand afrequently abreathe adeeply; araise athe ahead aof athe
abed;
increase aoral afluid aintake; aand ahumidify athe aoxygen aadministered, anone aof athese aactions awill
abe aas a
important aas aassessing athe alevel aof aconsciousness. aAlso, athe aclient awho ahas aa apulmonary
ainfection
a
may anot abe aable ato acough aeffectively aif aan aarea aof aabscess ais
apresent.
a
DIF:
aApplying
a
5. aA anurse ais aproviding acare aafter aauscultating aclients abreath asounds. aWhich aassessment
afinding ais a correctly amatched ato athe anurses aprimary aintervention? a
a. Hollow asounds aare aheard aover athe atrachea. aThe anurse aincreases athe aoxygen aflow arate. a
b. Crackles aare aheard ain abases. aThe anurse aencourages athe aclient ato acough aforcefully. a
c. Wheezes aare aheard ain acentral aareas. aThe anurse aadministers aan ainhaled abronchodilator. ad.
aVesicular asounds a are aheard aover athe aperiphery. a The anurse ahas athe a client abreathe adeeply. a-
aANS: aC aWheezes aare aindicative aof anarrowed aairways, aand abronchodilators ahelp ato aopen
athe aair apassages. a Hollow a sounds aare atypically aheard aover athe atrachea, aand ano aintervention
ais anecessary. aIf acrackles aare aheard, athe a client amay aneed aa adiuretic. aCrackles arepresent aa
adeep ainterstitial aprocess, aand acoughing aforcefully awill anot ahelp athe aclient aexpectorate
asecretions. aVesicular asounds aheard ain athe aperiphery aare anormal a and arequire ano
aintervention. a
DIF: aApplying a
a
,6. aA anurse aobserves athat aa aclients aanteroposterior a(AP) achest adiameter ais athe asame aas athe
alateral achest adiameter. a Which aquestion a should athe anurse aask athe aclient ain aresponse ato athis
afinding? aa. aAre ayou ataking aany amedications aor aherbal asupplements? a
b. Do ayou ahave aany achronic abreathing aproblems? a
c. How aoften ado ayou aperform aaerobic aexercise? a
d. What ais ayour aoccupation aand awhat aare ayour ahobbies? a- aANS: aB a
The anormal achest ahas aa alateral adiameter athat ais atwice aas alarge aas athe aAP adiameter. aWhen athe
aAP adiameter a approaches aor aexceeds athe alateral adiameter, athe aclient ais a said ato ahave aa abarrel
achest. a Most acommonly, abarrel achest aoccurs aas a a a result aof aa along-term achronic aairflow
alimitation aproblem, asuch a as achronic aobstructive a pulmonary adisease aor asevere achronic a asthma.
aIt acan a also abe aseen ain apeople a who ahave alived aat aa ahigh aaltitude afor amany ayears. aTherefore,
aan aAP achest adiameter athat ais athe asame a as athe alateral achest adiameter a should abe arechecked abut
ais anot aas aindicative aof aunderlying adisease aprocesses aas aan aAP adiameter athat aexceeds athe
alateral adiameter. a Medications, aherbal asupplements, aand a aerobic aexercise aare anot aassociated
awith aa abarrel achest. aAlthough aoccupation aand ahobbies amay aexpose a a aclient ato airritants athat
acan acause achronic alung adisorders aand abarrel achest, a
a
Test aBank a- aMedical-Surgical aNursing: aConcepts afor aInterprofessional aCollaborative aCare a9e
a215
a
aasking aabout achronic abreathing aproblems ais amore adirect aand a should abe a asked
afirst.
DIF: aApplying a
a
7. aA anurse ais aassessing aa aclient awho ais arecovering afrom aa alung abiopsy. aWhich aassessment
afinding a
a
requires aimmediate
aaction?
a
a. aIncreased a
atemperature
b. aAbsent abreath
asounds
a
c. aProductive
acough
a
d. aIncisional adiscomfort a- aANS:
aB
a
Absent abreath asounds amay aindicate athat athe aclient ahas aa apneumothorax, aa aserious
acomplication
a
after aa aneedle abiopsy aor aopen alung abiopsy. aThe aother amanifestations aare anot alife
athreatening.
a
DIF:
aApplying
a
8. aA anurse ais acaring afor aa aclient awho ais ascheduled ato aundergo aa athoracentesis. aWhich
aintervention ashould athe anurse acomplete aprior ato a the aprocedure? a
, a. Measure aoxygen asaturation abefore aand aafter aa a12-minute awalk. a
b. Verify athat athe aclient aunderstands aall apossible acomplications. a
c. Explain athe aprocedure ain adetail ato athe aclient aand athe afamily. a a
d. Validate athat ainformed aconsent ahas abeen agiven aby athe aclient. a- aANS: aD a
A athoracentesis ais aan ainvasive aprocedure awith amany apotentially aserious acomplications.
aVerifying athat athe aclient aunderstands acomplications aand aexplaining athe aprocedure ato abe
aperformed awill abe adone aby athe aphysician aor anurse apractitioner, anot athe anurse. aMeasurement
aof aoxygen a saturation abefore aand a after aa a12-minute awalk ais anot aa aprocedure aunique ato aa
athoracentesis. aDIF: a Applying a
a
9. aA anurse aassesses aa aclient aafter aa athoracentesis. aWhich aassessment afinding awarrants
aimmediate aaction? a a
a. The aclient arates apain aas aa a5-10 aat athe asite aof athe aprocedure. a
b. A asmall aamount aof adrainage afrom athe asite ais anoted. a
c. Pulse aoximetry ais a93% aon a2 aliters aof aoxygen. a
d. The atrachea ais adeviated atoward athe aopposite aside aof athe aneck. a- aANS: aD a
A adeviated atrachea ais aa amanifestation aof aa atension apneumothorax, awhich ais aa amedical
aemergency. aThe aother afindings aare anormal aor anear anormal. a
a
10. aA anurse acares afor aa aclient awho ahad aa abronchoscopy a2 ahours aago. aThe aclient aasks afor aa
adrink aof awater. aWhich aaction ashould athe anurse atake anext? a
a. Call athe aphysician aand arequest aa aprescription afor afood aand awater. a
b. Provide athe aclient awith aice achips ainstead aof aa adrink aof awater. a
c. Assess athe aclients agag areflex abefore agiving aany afood aor awater. a
d. Let athe aclient ahave aa asmall asip ato asee awhether ahe aor ashe acan aswallow. a- aANS: aC a
The atopical aanesthetic aused aduring athe aprocedure awill ahave aaffected athe aclients agag areflex.
aBefore aallowing athe aclient aanything ato aeat aor adrink, athe anurse amust acheck afor athe areturn aof
athis areflex. aDIF: aApplying a
a
11. aA anurse aplans acare afor aa aclient awho ais aexperiencing adyspnea aand amust astop amultiple
atimes awhen aclimbing aa aflight aof astairs. a Which aintervention ashould athe anurse ainclude ain athis
aclients aplan aof a care? a
a. Assistance awith aactivities aof adaily aliving a
b. Physical atherapy aactivities aevery aday a
c. Oxygen atherapy aat a2 aliters aper anasal acannula ad. aComplete abedrest awith afrequent
arepositioning a- a
ANS: aA a
A aclient awith adyspnea aand adifficulty acompleting aactivities asuch aas aclimbing aa aflight aof astairs
ahas aclass aIII adyspnea. aThe anurse a should aprovide aassistance awith a activities aof adaily aliving.
aThese aclients a should abe aencouraged ato aparticipate ain a activities aas atolerated. aThey a should anot
abe aon acomplete abedrest, amay anot abe aable ato atolerate adaily aphysical atherapy, aand aonly aneed
aoxygen aif ahypoxia ais apresent. a
DIF: aApplying a
a
