NURS 320 Final Exam
A charge nurse is providing an in-service to a group of staff
nurses about endotracheal suctioning. Which of the following
statements by a staff nurse indicates an understanding of the
teaching?
A. "I will use clean technique when suctioning a client's
endotracheal tube."
B. "I will use a rotating motion when removing the suction
catheter."
C. "I will suction the oropharyngeal cavity prior to suctioning
the endotracheal tube."
D. "I will suction a client's endotracheal tube every 2 hours."
Correct Answers B. "I will use a rotating motion when
removing the suction catheter."
A charge nurse is reviewing the care of a client who has a chest
tube connected to a water seal drainage system in a place
following thoracic surgery w/ newly licensed nurse. Which of
the following statements by the newly licensed nurse indicates
an understanding of when to notify the provider?
A. "I will notify the provider if there is a fluctuation of drainage
in the tubing with inspiration."
B. "I will notify the provider if there is continuous bubbling in
the water seal chamber."
C. "I will notify the provider if there is drainage of 60 milliliters
in the first hour after surgery."
D. "I will notify the provider if there are several small, dark-red
blood clots in the tubing." Correct Answers B. "I will notify the
,provider if there is continuous bubbling in the water seal
chamber."
Rationale: Continuous bubbling in the water seal chamber
suggests an air leak and requires notification of the provider.
A home health nurse is teaching a client who has active TB and
is following a four-drug medication regimen. Which of the
following statements indicates understanding? Select all that
apply.
a. "I will wash my hands each time I cough"
b. "I will wear a mask when I am in a public area"
c. "I am glad I don't have to have any more sputum specimens"
d. " I don't need to worry where I go once I start taking my
medications" Correct Answers a and b
A nurse developing a plan of care for a client who has active
TB. which of the following isolation precautions should the
nurse include in the plan?
A. Airborne
B. Neutropenic
C. Contact
D. Droplet Correct Answers A. Airborne
A nurse in a provider's office is assessing a client who has
COPD. Which of the following findings is the priority for the
nurse to report to the provider?
A. Increased anterior-posterior chest diameter
,B. Productive cough with green sputum
C. Clubbing of the fingers
D. Pursed-lip breathing with exertion Correct Answers B.
Productive cough with green sputum
Rationale: Productive cough with green sputum is indicative of
an infection. The other answer choices are expected findings in a
client with COPD.
A nurse in an ED is caring for a client who's experiencing a
pulmonary embolism. Which of the following actions should the
nurse take first?
A. Apply supplemental oxygen.
B. Increase the rate of IV fluids.
C. Administer pain medication.
D. Initiate cardiac monitoring. Correct Answers A. Apply
supplemental oxygen.
A nurse in an ED is caring for a client who's experiencing acute
respiratory failure. Which of the following lab findings should
the nurse expect?
A. Arterial pH 7.50
B. PaCO2 25 mm Hg
C. SaO2 92%
D. PaO2 58 mm Hg Correct Answers D. PaO2 58 mm Hg
A nurse in an emergency department is caring for a client who
had an anterior myocardial infarction. The client's history
reveals she is 1 week post-op following an open
, cholecystectomy. The nurse should recognize that which of the
following interventions is
contraindicated?
a. Administering IV morphine sulfate
b. Administering oxygen at 2 L/min via nasal cannula
c. Helping the client to the bedside commode
d. Assisting with thrombolytic therapy Correct Answers d.
Assisting with thrombolytic therapy
A nurse in an emergency department s caring for a client who
has a blood pressure of 254/139 mm hg. The nurse recognizes
that the client is in a hypertensive crisis. Which of the following
actions should the nurse take first.
a. Tell the client to report vision changes
b. Elevate the head of the clients bed
c. Start a peripheral IV
d. Initiate Seizure precautions Correct Answers b. Elevate the
head of the clients bed
A nurse in an emergency room is assessing a client who has
bradydysrhythmia. Which of the following findings should the
nurse monitor for?
a. Friction Rub
b. Confusion
c. Dry Skin
d. Hypertension Correct Answers b. Confusion
A charge nurse is providing an in-service to a group of staff
nurses about endotracheal suctioning. Which of the following
statements by a staff nurse indicates an understanding of the
teaching?
A. "I will use clean technique when suctioning a client's
endotracheal tube."
B. "I will use a rotating motion when removing the suction
catheter."
C. "I will suction the oropharyngeal cavity prior to suctioning
the endotracheal tube."
D. "I will suction a client's endotracheal tube every 2 hours."
Correct Answers B. "I will use a rotating motion when
removing the suction catheter."
A charge nurse is reviewing the care of a client who has a chest
tube connected to a water seal drainage system in a place
following thoracic surgery w/ newly licensed nurse. Which of
the following statements by the newly licensed nurse indicates
an understanding of when to notify the provider?
A. "I will notify the provider if there is a fluctuation of drainage
in the tubing with inspiration."
B. "I will notify the provider if there is continuous bubbling in
the water seal chamber."
C. "I will notify the provider if there is drainage of 60 milliliters
in the first hour after surgery."
D. "I will notify the provider if there are several small, dark-red
blood clots in the tubing." Correct Answers B. "I will notify the
,provider if there is continuous bubbling in the water seal
chamber."
Rationale: Continuous bubbling in the water seal chamber
suggests an air leak and requires notification of the provider.
A home health nurse is teaching a client who has active TB and
is following a four-drug medication regimen. Which of the
following statements indicates understanding? Select all that
apply.
a. "I will wash my hands each time I cough"
b. "I will wear a mask when I am in a public area"
c. "I am glad I don't have to have any more sputum specimens"
d. " I don't need to worry where I go once I start taking my
medications" Correct Answers a and b
A nurse developing a plan of care for a client who has active
TB. which of the following isolation precautions should the
nurse include in the plan?
A. Airborne
B. Neutropenic
C. Contact
D. Droplet Correct Answers A. Airborne
A nurse in a provider's office is assessing a client who has
COPD. Which of the following findings is the priority for the
nurse to report to the provider?
A. Increased anterior-posterior chest diameter
,B. Productive cough with green sputum
C. Clubbing of the fingers
D. Pursed-lip breathing with exertion Correct Answers B.
Productive cough with green sputum
Rationale: Productive cough with green sputum is indicative of
an infection. The other answer choices are expected findings in a
client with COPD.
A nurse in an ED is caring for a client who's experiencing a
pulmonary embolism. Which of the following actions should the
nurse take first?
A. Apply supplemental oxygen.
B. Increase the rate of IV fluids.
C. Administer pain medication.
D. Initiate cardiac monitoring. Correct Answers A. Apply
supplemental oxygen.
A nurse in an ED is caring for a client who's experiencing acute
respiratory failure. Which of the following lab findings should
the nurse expect?
A. Arterial pH 7.50
B. PaCO2 25 mm Hg
C. SaO2 92%
D. PaO2 58 mm Hg Correct Answers D. PaO2 58 mm Hg
A nurse in an emergency department is caring for a client who
had an anterior myocardial infarction. The client's history
reveals she is 1 week post-op following an open
, cholecystectomy. The nurse should recognize that which of the
following interventions is
contraindicated?
a. Administering IV morphine sulfate
b. Administering oxygen at 2 L/min via nasal cannula
c. Helping the client to the bedside commode
d. Assisting with thrombolytic therapy Correct Answers d.
Assisting with thrombolytic therapy
A nurse in an emergency department s caring for a client who
has a blood pressure of 254/139 mm hg. The nurse recognizes
that the client is in a hypertensive crisis. Which of the following
actions should the nurse take first.
a. Tell the client to report vision changes
b. Elevate the head of the clients bed
c. Start a peripheral IV
d. Initiate Seizure precautions Correct Answers b. Elevate the
head of the clients bed
A nurse in an emergency room is assessing a client who has
bradydysrhythmia. Which of the following findings should the
nurse monitor for?
a. Friction Rub
b. Confusion
c. Dry Skin
d. Hypertension Correct Answers b. Confusion
