NUR 170 EXAM 2 /NUR170 Exam 2 Actual
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A client is being discharged home with a tracheostomy. Which statement
by the client indicates the need for further teaching about correct
tracheostomy care?
"I can only take baths, but no showers."
"I can put normal saline in my tracheostomy to keep the secretions from
getting thick."
"I should put cotton or foam over the tracheostomy hole."
"I will be unable to wear a necklace."
The nurse is caring for a client who has had a tracheostomy placed
yesterday. Which of these assessments is essential for the nurse to make?
Assess for tachypnea.
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The nurse is caring for a client with COPD who has a prescription for
supplemental oxygen. Which situation will cause the nurse to further
assess the need to increase the fraction of inspired oxygen (FiO2)?
Client has developed restlessness over the last hour
The nurse on a pulmonary unit is caring for a client who has had a
tracheostomy placed earlier today. Which of these techniques
representing best practice will use the nurse use when suctioning the
client's tracheostomy tube?
Hyperoxygenate before and after suctioning.
A client with chronic obstructive pulmonary disease (COPD) has a
prescription to adjust oxygen to maintain SpO2 between 90% and 92%.
Which action can be delegated to an unlicensed assistive personnel
(UAP) under the supervision of an RN?
Adjust the position of the oxygen tubing.
An older adult client is being discharged home with a tracheostomy.
Which nursing action is an acceptable assignment for an experienced
LPN/LVN?
Suction the tracheostomy using sterile technique.
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A client who smokes is being discharged home on oxygen. The client
states, "My lungs are already damaged, so I'm not going to quit
smoking." What is the discharge nurse's best response?
"Let's discuss why smoking around oxygen is dangerous."
A client who has a "do not resuscitate" (DNR) prescription has a non-
rebreather oxygen mask, and breathing appears to be labored. What does
the nurse do first?
Ensure that the tubing is patent and that oxygen flow is high.
The interprofessional team is collaborating about using noninvasive
positive-pressure ventilation (NPPV) for a confused client with
pneumonia. What information is essential for the nurse to share with the
team while making this decision?
The client is unable to cough and protect the airway.
The adult client with degenerative arthritis is admitted for surgery to
create a tracheostomy. What is the best communication method for this
client during the postoperative period?
Picture board
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The nurse is developing the plan of care to reduce risk for aspiration for
a client with a tracheostomy. Which nursing interventions would be
included in the plan of care?
Maintain the client upright for 30 minutes after eating.
Provide small, frequent meals.
Teach the client to "tuck" the chin down in the forward position to
swallow.
A registered nurse (RN) from the orthopedic unit has been assigned to
the medical unit for the day. Which client assignment for the reassigned
RN is the best?
The client with a resolving pulmonary embolus who is receiving oxygen
at 6 L/min through a nasal cannula
The nurse is assigned to care for a client with complete right-sided
hemiparesis from a stroke (brain attack). Which characteristics are
associated with this condition? Select all that apply
The client is aphasic.
The client has weakness on the right side of the body