UNRS 107 Quiz2_Prep_Rationale - ATI Quiz
#2 Prep Questions With Complete Solutions
Graded A+
1. A nurse is administering nasal decongestant drops for a client. Which
of the following actions should the nurse
take?
A. Tell the client to blow her nose gently before the instillation.
B. Assist the client to a side-lying position.
C. Hold the dropper 2 cm (1 in) above the naris.
D. Instruct the client to stay in the same position for 2 min. - ANSWER
A. Tell the client to blow her nose gently before the instillation.
Rationale: Prior to instillation, the nurse should instruct the client to
blow her nose gently. This action will help remove any secretions or
crusts that could interfere with the distribution and absorption of
the medication
, 2. A nurse is performing tracheostomy care for a client and suctioning to
remove copious secretions. Which of the following actions should the
nurse take?
A. Suction two to three times with a 60-second pause between passes
B. Perform chest physiotherapy prior to suctioning.
C. Lubricate the suction catheter tip with sterile saline.
D. Hyperventilate the client on 100% oxygen prior to suctioning. -
ANSWER A. Suction two to three times with a 60-second pause
between passes.
Rationale: Copious secretions may require several passes of the suction
catheter. An interval of 60 seconds should be allowed between passes to
prevent hypoxia.
3. A nurse is caring for a client who has chronic obstructive pulmonary
disease (COPD). The client tells the nurse, "I can feel the congestion in
my lungs, and I certainly cough a lot, but I can't seem to bring anything
up." Which of the following actions should the nurse take to help this
client with tenacious bronchial secretions?
A. Maintaining a semi-Fowler's position as often as possible
, B. Administering oxygen via nasal cannula at 2 L/min
C. Helping the client select a low-salt diet
D. Encouraging the client to drink 2 to 3 L of water daily - ANSWER D.
Encouraging the client to drink 2 to 3 L of water daily
Rationale: COPD is a term for two diseases of the respiratory system:
chronic bronchitis and emphysema.
Maintaining hydration through the consumption of adequate fluids will
help liquefy thick secretions and facilitate their expectoration.
4. A nurse is attending a social event when another guest coughs weakly
once, grasps his throat with his hands, and cannot talk. Which of the
following actions should the nurse should take?
A. Observe the client before taking further action.
B. Perform the Heimlich maneuver.
C. Assist the client to the floor and begin mouth-to-mouth resuscitation.
D. Slap the client on the back several times. - ANSWER B. Perform the
Heimlich maneuver.
#2 Prep Questions With Complete Solutions
Graded A+
1. A nurse is administering nasal decongestant drops for a client. Which
of the following actions should the nurse
take?
A. Tell the client to blow her nose gently before the instillation.
B. Assist the client to a side-lying position.
C. Hold the dropper 2 cm (1 in) above the naris.
D. Instruct the client to stay in the same position for 2 min. - ANSWER
A. Tell the client to blow her nose gently before the instillation.
Rationale: Prior to instillation, the nurse should instruct the client to
blow her nose gently. This action will help remove any secretions or
crusts that could interfere with the distribution and absorption of
the medication
, 2. A nurse is performing tracheostomy care for a client and suctioning to
remove copious secretions. Which of the following actions should the
nurse take?
A. Suction two to three times with a 60-second pause between passes
B. Perform chest physiotherapy prior to suctioning.
C. Lubricate the suction catheter tip with sterile saline.
D. Hyperventilate the client on 100% oxygen prior to suctioning. -
ANSWER A. Suction two to three times with a 60-second pause
between passes.
Rationale: Copious secretions may require several passes of the suction
catheter. An interval of 60 seconds should be allowed between passes to
prevent hypoxia.
3. A nurse is caring for a client who has chronic obstructive pulmonary
disease (COPD). The client tells the nurse, "I can feel the congestion in
my lungs, and I certainly cough a lot, but I can't seem to bring anything
up." Which of the following actions should the nurse take to help this
client with tenacious bronchial secretions?
A. Maintaining a semi-Fowler's position as often as possible
, B. Administering oxygen via nasal cannula at 2 L/min
C. Helping the client select a low-salt diet
D. Encouraging the client to drink 2 to 3 L of water daily - ANSWER D.
Encouraging the client to drink 2 to 3 L of water daily
Rationale: COPD is a term for two diseases of the respiratory system:
chronic bronchitis and emphysema.
Maintaining hydration through the consumption of adequate fluids will
help liquefy thick secretions and facilitate their expectoration.
4. A nurse is attending a social event when another guest coughs weakly
once, grasps his throat with his hands, and cannot talk. Which of the
following actions should the nurse should take?
A. Observe the client before taking further action.
B. Perform the Heimlich maneuver.
C. Assist the client to the floor and begin mouth-to-mouth resuscitation.
D. Slap the client on the back several times. - ANSWER B. Perform the
Heimlich maneuver.
