NURA 308 exam 3 UPDATED ACTUAL
Exam Questions and CORRECT Answers
The nurse has provided education to a client diagnosed with a pleural effusion who is scheduled
for a thoracentesis. Which client statement indicates an understanding of the teaching?
A. "I will have a tube left in my chest to drain the fluid."
B. "The fluid removed during the procedure can be examined to determine what caused the
pleural effusion."
C. "I will be under general anesthesia during the procedure."
D. "During the procedure, an antibiotic will be put into the needle to prevent a lung infection." -
CORRECT ANSWER - B. "The fluid removed during the procedure can be examined to
determine what caused the pleural effusion."
When caring for a client diagnosed with pleural effusion, the nurse should begin by explaining
that pleural effusion is an accumulation of fluid around the outside of the lungs that makes
breathing harder for them. The nurse should let clients know that the extra fluid will be drained
during a thoracentesis and analyzed to confirm the cause of the effusion. After this procedure,
nurses should reassure clients that they will be monitored closely for ongoing respiratory
problems, pain, bleeding, or infection.
The nurse in the post-anesthesia care unit (PACU) is caring for a client who underwent a
thoracentesis to treat pleural effusion. The client's lung sounds are clear, oxygen saturation is
96% on room air, and respiratory rate is 20/min. Which is the nurse's priority intervention?
A. Place the client's head on the bed at 30°
B. Obtain a respiratory therapist consultation
C. Instruct the client on how to use an incentive spirometer.
D. Administer supplemental oxygen - CORRECT ANSWER - A. Place the client's head on the
bed at 30°
,The nurse should place the client's head on the bed at 30° to facilitate lung expansion,
oxygenation, ventilation, and decrease the work of breathing before performing other
interventions.
The nurse is caring for a client diagnosed with a large pleural effusion who is experiencing pain
upon inhalation and a dry cough. For which procedure should the nurse prepare the client?
A. Chemical pleurodesis
B. Pneumonectomy
C. Bronchoscopy
D. Thoracentesis - CORRECT ANSWER - D. Thoracentesis
A thoracentesis is when a needle is inserted through the chest wall into the pleural space to
remove the fluid. This is a treatment for large pleural effusions.
While reviewing the electronic health record (EHR) of a client diagnosed with pleural effusion,
the nurse notes the client's condition is caused by transudate fluid accumulation. Which condition
should the nurse associate with this finding?
A. Cataracts
B. Gout
C. Nephrotic syndrome
D. Type 2 diabetes mellitus (DM) - CORRECT ANSWER - C. Nephrotic syndrome
Nephrotic syndrome occurs when there is damage to small blood vessels in the kidney, adversely
affecting the renal filtration system and resulting in protein loss. Nephrotic syndrome is
associated with the development of pleural effusion caused by transudate fluid build-up.
The nurse assesses a client diagnosed with a pleural effusion. Which clinical finding should the
nurse anticipate?
A. Sharp pain upon expiration
,B. Resonance on the affected side during percussion
C. Stridor
D. Dry cough - CORRECT ANSWER - D. Dry cough
A small pleural effusion typically causes no clinical manifestations. With more significant pleural
effusions, clients may present with dyspnea, dry cough, and sharp pain that comes with
inspiration. During auscultation, the affected side has reduced or absent breath sounds. On
percussion, there is dullness due to the presence of fluid within the pleural space.
The nurse is caring for a client suspected of having a pleural effusion. For which diagnostic
testing should the nurse prepare the client?
A. Chest x-ray
B. Spirometry
C. Gas diffusion test
D. Echocardiogram - CORRECT ANSWER - A. Chest x-ray
The diagnosis of pleural effusion starts with the client's history and physical assessment,
followed by a chest X-ray or computed tomography (CT) scan to visualize the flow. A large
effusion might also show a collapsed lung. Diagnostic thoracentesis is also frequently done.
Thoracentesis is a procedure involving collecting fluid from the pleural space to determine its
composition, which helps to find out the cause. When examining pleural fluid, the main
difference is that exudative effusions are rich in protein or lactate dehydrogenase (LDH), while
transudative effusions are not.
The nurse is reviewing the physiology of the pleural space with a newly graduated nurse. Which
statement should the nurse include in the teaching?
A. "The fluid in the pleural space provides lubrication for the pleural layers during breathing."
B. "The pleural fluid is replaced during inspiration, preventing the collapse of the lungs."
C. "The lymphatic vessels hold a reserve of fluid which is used by the cells in the pleural space."
, D. "The type I pneumocyte cells in the lungs secrete the fluid into the pleural space." -
CORRECT ANSWER - A. "The fluid in the pleural space provides lubrication for the pleural
layers during breathing."
The pleural space contains 20 to 25 milliliters of fluid that provides lubrication, allowing the two
pleural layers to slide over each other during breathing.
A nurse in the intensive care unit (ICU) is caring for a client with an endotracheal tube who is
receiving mechanical ventilation. The nurse should recognize that the client is at risk for which
complication(s)? Select all that apply.
A. Hospital-acquired pressure injury
B. Deep vein thrombosis
C. Respiratory barotrauma
D. Malnutrition
E. Community-acquired pneumonia (CAP) - CORRECT ANSWER - A, B, C, D
When a client undergoes intubation and is placed on mechanical ventilation, the client is at an
increased risk of developing complications such as infection, airway trauma, pressure injury,
deep vein thrombosis, and malnutrition. One of the main risks of mechanical ventilation is a
particular type of infection called ventilator-associated pneumonia, or VAP. This occurs when
bacteria invade the lungs through the ETT. Intubated clients can also develop barotrauma and
ventilator-induced lung injuries, which occur when the pressure of ventilation is so high that it
causes the alveoli to rupture. In addition, intubated clients are generally sedated and paralyzed
temporarily with IV medications to provide comfort and to ensure they don't resist the ETT and
damage their airway. However, this immobility can increase the risk of developing pressure
injuries and deep vein thrombosis. Lastly, malnutrition can result since intubation means the
client can't ingest food or fluids by mouth since their swallowing ability is compromised.
Awareness of these potential complications is important since the nurse plays an important role
in prevention.
A nurse in the intensive care unit (ICU) is caring for a client who has been intubated for 24
hours. What steps should the nurse take to prevent ventilator-associated pneumonia (VAP) in this
client?
Exam Questions and CORRECT Answers
The nurse has provided education to a client diagnosed with a pleural effusion who is scheduled
for a thoracentesis. Which client statement indicates an understanding of the teaching?
A. "I will have a tube left in my chest to drain the fluid."
B. "The fluid removed during the procedure can be examined to determine what caused the
pleural effusion."
C. "I will be under general anesthesia during the procedure."
D. "During the procedure, an antibiotic will be put into the needle to prevent a lung infection." -
CORRECT ANSWER - B. "The fluid removed during the procedure can be examined to
determine what caused the pleural effusion."
When caring for a client diagnosed with pleural effusion, the nurse should begin by explaining
that pleural effusion is an accumulation of fluid around the outside of the lungs that makes
breathing harder for them. The nurse should let clients know that the extra fluid will be drained
during a thoracentesis and analyzed to confirm the cause of the effusion. After this procedure,
nurses should reassure clients that they will be monitored closely for ongoing respiratory
problems, pain, bleeding, or infection.
The nurse in the post-anesthesia care unit (PACU) is caring for a client who underwent a
thoracentesis to treat pleural effusion. The client's lung sounds are clear, oxygen saturation is
96% on room air, and respiratory rate is 20/min. Which is the nurse's priority intervention?
A. Place the client's head on the bed at 30°
B. Obtain a respiratory therapist consultation
C. Instruct the client on how to use an incentive spirometer.
D. Administer supplemental oxygen - CORRECT ANSWER - A. Place the client's head on the
bed at 30°
,The nurse should place the client's head on the bed at 30° to facilitate lung expansion,
oxygenation, ventilation, and decrease the work of breathing before performing other
interventions.
The nurse is caring for a client diagnosed with a large pleural effusion who is experiencing pain
upon inhalation and a dry cough. For which procedure should the nurse prepare the client?
A. Chemical pleurodesis
B. Pneumonectomy
C. Bronchoscopy
D. Thoracentesis - CORRECT ANSWER - D. Thoracentesis
A thoracentesis is when a needle is inserted through the chest wall into the pleural space to
remove the fluid. This is a treatment for large pleural effusions.
While reviewing the electronic health record (EHR) of a client diagnosed with pleural effusion,
the nurse notes the client's condition is caused by transudate fluid accumulation. Which condition
should the nurse associate with this finding?
A. Cataracts
B. Gout
C. Nephrotic syndrome
D. Type 2 diabetes mellitus (DM) - CORRECT ANSWER - C. Nephrotic syndrome
Nephrotic syndrome occurs when there is damage to small blood vessels in the kidney, adversely
affecting the renal filtration system and resulting in protein loss. Nephrotic syndrome is
associated with the development of pleural effusion caused by transudate fluid build-up.
The nurse assesses a client diagnosed with a pleural effusion. Which clinical finding should the
nurse anticipate?
A. Sharp pain upon expiration
,B. Resonance on the affected side during percussion
C. Stridor
D. Dry cough - CORRECT ANSWER - D. Dry cough
A small pleural effusion typically causes no clinical manifestations. With more significant pleural
effusions, clients may present with dyspnea, dry cough, and sharp pain that comes with
inspiration. During auscultation, the affected side has reduced or absent breath sounds. On
percussion, there is dullness due to the presence of fluid within the pleural space.
The nurse is caring for a client suspected of having a pleural effusion. For which diagnostic
testing should the nurse prepare the client?
A. Chest x-ray
B. Spirometry
C. Gas diffusion test
D. Echocardiogram - CORRECT ANSWER - A. Chest x-ray
The diagnosis of pleural effusion starts with the client's history and physical assessment,
followed by a chest X-ray or computed tomography (CT) scan to visualize the flow. A large
effusion might also show a collapsed lung. Diagnostic thoracentesis is also frequently done.
Thoracentesis is a procedure involving collecting fluid from the pleural space to determine its
composition, which helps to find out the cause. When examining pleural fluid, the main
difference is that exudative effusions are rich in protein or lactate dehydrogenase (LDH), while
transudative effusions are not.
The nurse is reviewing the physiology of the pleural space with a newly graduated nurse. Which
statement should the nurse include in the teaching?
A. "The fluid in the pleural space provides lubrication for the pleural layers during breathing."
B. "The pleural fluid is replaced during inspiration, preventing the collapse of the lungs."
C. "The lymphatic vessels hold a reserve of fluid which is used by the cells in the pleural space."
, D. "The type I pneumocyte cells in the lungs secrete the fluid into the pleural space." -
CORRECT ANSWER - A. "The fluid in the pleural space provides lubrication for the pleural
layers during breathing."
The pleural space contains 20 to 25 milliliters of fluid that provides lubrication, allowing the two
pleural layers to slide over each other during breathing.
A nurse in the intensive care unit (ICU) is caring for a client with an endotracheal tube who is
receiving mechanical ventilation. The nurse should recognize that the client is at risk for which
complication(s)? Select all that apply.
A. Hospital-acquired pressure injury
B. Deep vein thrombosis
C. Respiratory barotrauma
D. Malnutrition
E. Community-acquired pneumonia (CAP) - CORRECT ANSWER - A, B, C, D
When a client undergoes intubation and is placed on mechanical ventilation, the client is at an
increased risk of developing complications such as infection, airway trauma, pressure injury,
deep vein thrombosis, and malnutrition. One of the main risks of mechanical ventilation is a
particular type of infection called ventilator-associated pneumonia, or VAP. This occurs when
bacteria invade the lungs through the ETT. Intubated clients can also develop barotrauma and
ventilator-induced lung injuries, which occur when the pressure of ventilation is so high that it
causes the alveoli to rupture. In addition, intubated clients are generally sedated and paralyzed
temporarily with IV medications to provide comfort and to ensure they don't resist the ETT and
damage their airway. However, this immobility can increase the risk of developing pressure
injuries and deep vein thrombosis. Lastly, malnutrition can result since intubation means the
client can't ingest food or fluids by mouth since their swallowing ability is compromised.
Awareness of these potential complications is important since the nurse plays an important role
in prevention.
A nurse in the intensive care unit (ICU) is caring for a client who has been intubated for 24
hours. What steps should the nurse take to prevent ventilator-associated pneumonia (VAP) in this
client?
