Timby's Introductory Medical-Surgical Nursing
13th Edition Moreno Test Bank Advanced/Hard
Difficulty | For Nursing Students | 100% Pass
Guaranteed | Graded A+
,Question 1
A client is admitted with a diagnosis of pneumonia. The nurse auscultates crackles in the lung
bases and notes a productive cough with green sputum. Which nursing diagnosis is the priority?
A. Ineffective Airway Clearance
B. Impaired Gas Exchange
C. Risk for Infection
D. Activity Intolerance
Correct Answer: A
☑ Explanation: Ineffective Airway Clearance is the priority because the client has
crackles and productive cough, indicating secretions that need to be cleared. Impaired Gas
Exchange is a later concern; Risk for Infection is relevant but not immediate; Activity Intolerance
is a consequence, not the primary issue.
Question 2
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via
nasal cannula. The nurse notes that the client's respiratory rate has decreased to 8 breaths per
,minute. Which action should the nurse take first?
A. Increase the oxygen flow to 4 L/min
B. Assess the client's level of consciousness
C. Notify the healthcare provider
D. Encourage the client to cough and deep breathe
Correct Answer: B
☑ Explanation: The decrease in respiratory rate may indicate CO₂ retention and
respiratory depression, especially in COPD clients on oxygen. The nurse should first assess the
client's level of consciousness to evaluate for signs of CO₂ narcosis. Increasing oxygen could
worsen the problem; notifying the provider is appropriate after assessment.
Question 3
The nurse is preparing to administer a blood transfusion to a client. Which action is most
important to prevent a transfusion reaction?
A. Verify the client's identity and blood product with another licensed nurse using two
identifiers
B. Warm the blood product to body temperature before administration
, C. Administer the blood over 30 minutes
D. Pre-medicate the client with diphenhydramine
Correct Answer: A
☑ Explanation: Verification of client identity and blood product with another
licensed nurse using two identifiers is the most critical safety measure to prevent transfusion
reactions due to ABO incompatibility. Warming blood, administration rate, and pre-medication
are secondary considerations.
Question 4
A client with heart failure is prescribed furosemide (Lasix) 40 mg IV. Which assessment finding
indicates the medication is effective?
A. Decreased urine output
B. Increased blood pressure
C. Decreased dyspnea and weight loss
D. Increased heart rate
13th Edition Moreno Test Bank Advanced/Hard
Difficulty | For Nursing Students | 100% Pass
Guaranteed | Graded A+
,Question 1
A client is admitted with a diagnosis of pneumonia. The nurse auscultates crackles in the lung
bases and notes a productive cough with green sputum. Which nursing diagnosis is the priority?
A. Ineffective Airway Clearance
B. Impaired Gas Exchange
C. Risk for Infection
D. Activity Intolerance
Correct Answer: A
☑ Explanation: Ineffective Airway Clearance is the priority because the client has
crackles and productive cough, indicating secretions that need to be cleared. Impaired Gas
Exchange is a later concern; Risk for Infection is relevant but not immediate; Activity Intolerance
is a consequence, not the primary issue.
Question 2
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via
nasal cannula. The nurse notes that the client's respiratory rate has decreased to 8 breaths per
,minute. Which action should the nurse take first?
A. Increase the oxygen flow to 4 L/min
B. Assess the client's level of consciousness
C. Notify the healthcare provider
D. Encourage the client to cough and deep breathe
Correct Answer: B
☑ Explanation: The decrease in respiratory rate may indicate CO₂ retention and
respiratory depression, especially in COPD clients on oxygen. The nurse should first assess the
client's level of consciousness to evaluate for signs of CO₂ narcosis. Increasing oxygen could
worsen the problem; notifying the provider is appropriate after assessment.
Question 3
The nurse is preparing to administer a blood transfusion to a client. Which action is most
important to prevent a transfusion reaction?
A. Verify the client's identity and blood product with another licensed nurse using two
identifiers
B. Warm the blood product to body temperature before administration
, C. Administer the blood over 30 minutes
D. Pre-medicate the client with diphenhydramine
Correct Answer: A
☑ Explanation: Verification of client identity and blood product with another
licensed nurse using two identifiers is the most critical safety measure to prevent transfusion
reactions due to ABO incompatibility. Warming blood, administration rate, and pre-medication
are secondary considerations.
Question 4
A client with heart failure is prescribed furosemide (Lasix) 40 mg IV. Which assessment finding
indicates the medication is effective?
A. Decreased urine output
B. Increased blood pressure
C. Decreased dyspnea and weight loss
D. Increased heart rate
