Answers
1. A client with a productive cough has obtained a sputum specimen for culture as
instructed. What is the best initial nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab for analysis Ans: B. Observe the color, consistency,
and amount of sputum
2. A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary
resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen
per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and
diaphoretic. Which assessment is most important for the nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature Ans: A. Breath sounds over bilateral lung fields.
3. After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone
(SIADH), a client develops pontine myselinolysis. Which intervention should the nurse
implement first?
,A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises Ans: A. Reorient client to his room
4. A male client with heart failure (HF) calls the clinic and reports that he cannot put
his shoes on because they are too tight. Which additional information should the nurse
obtain?
A. What time did he take his last medications?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night? Ans: B. Has his weight changed in the last
several days?
5. An older adult woman with a long history of chronic obstructive pulmonary disease
(COPD) is admitted with progressive shortness of breath and a persistent cough. She
is anxious and is complaining of a dry mouth. Which intervention should the nurse
implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high-flow venturi mask
© Get it right 2025 Getaway - Stuvia US All rights reserved
, D. Assist her to an upright position Ans: D. Assist her to an upright position
6. A client with a history of asthma and bronchitis arrives at the clinic with shortness
of breath, productive cough with thickened tenacious mucous, and the inability to walk
up a flight of stairs without experiencing breathlessness. Which action is most
important for the nurse to instruct the client about self-care?
A. Increase the daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogen exposure
C. Call the clinic if undesirable side effects of mediations occur
D. Teach anxiety reduction methods for feelings of suffocation Ans: A. Increase the
daily intake of oral fluids to liquefy secretions
7. A cardiac catherterization of a client with heart disease indicates the following
blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and
? % proximal right coronary artery (RCA). The client later asks the nurse "what does
all this mean for me?" What information should the nurse provide?
A. Blood supply to the heart is diminished by artherosclerotic lesions, which
necessitate lifestyle changes.
B. Blood vessels supplying the pumping chamber have blockages indicating a past heart
attack.
C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting
through to the heart muscle.
© Get it right 2025 Getaway - Stuvia US All rights reserved