a nurse is caring for a client who's receiving mechanical ventilation when the low-
pressure alarm sounds. which of the following situations should the nurse recognize as
a possible cause of the alarm?
A.) Excess secretions
B.) Kinks in the tubing
C.) Artificial airway cuff leak
D.) Biting on the endotracheal tube - ANSWER>>artificial airway cuff leak
rationale:
An artificial airway cuff leak interferes with oxygenation and causes the low-pressure
alarm to sound.
a nurse is providing discharge teaching to a client who has a temporary tracheostomy.
which of the following statements by the client indicates an understanding of the
teaching?
A.) "Ringing in the ears is an adverse effect of this medication."
B.) "Have your skin test repeated in 4 months to show a positive result."
C.) "Expect your urine and other secretions to be orange while taking this medication."
D.) "Remember to take this medication with a sip of water just before your first bite of
each meal." - ANSWER>>"I should remove the old twill ties after the new ties are in
place."
rationale:
,As a safety measure, the nurse should teach the client to wait until the new ties are in
place to remove the old ties. This practice can prevent accidental decannulation.
a nurse is caring for 4 clients. which of the following clients is at greatest risk for a
pulmonary embolism?
A.) A client who is 48 hr postoperative following a total hip arthroplasty
B.) A client who is 8 hr postoperative following an open surgical appendectomy
C.) A client who is 2 hr postoperative following an open reduction external fixation of the
right radius
D.) A client who is 4 hr postoperative following a laparoscopic cholecystectomy -
ANSWER>>A client who is 48 hr postoperative following a total hip arthroplasty
rationale:
The nurse should identify that a client who has undergone a total hip arthroplasty
surgery is at greatest risk for a pulmonary embolus because of decreased mobility of
the affected extremity and an increased amount of blood clots forming in the veins of
the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72
hr following the arthroplasty. The nurse should intervene to reduce the risk by applying
sequential compression devices or antiembolic stockings and by administering
anticoagulant medications.
a nurse is caring for a newly admitted client who has emphysema. the nurse should
place the client in which of the following positions to promote effective breathing?
A.) Lateral position with a pillow at the back and over the chest to support the arm
B.) High-Fowler's position with the arms supported on the overbed table
C.) NNSemi-Fowler's NNposition NNwith NNpillows NNsupporting NNboth NNarms
D.) NNSupine NNposition NNwith NNthe NNhead NNof NNthe NNbed NNelevated NNto NN15° NN-
NN ANSWER>>High-Fowler'sNposition NNwith NNthe NNarms NNsupported NNon NNthe NNoverbed
table
NN
,rationale:
The NNnurse NNshould NNplace NNthe NNclient NNin NNa NNposition NNthat NNallows NNfor NNgreater
NN expansion NNof NNtheNchest, NNsuch NNas NNsitting NNupright NNand NNleaning NNslightly NNforward
NN while NNsupporting NNboth NNarms NNwith NNpillows NNfor NNcomfort NNon NNthe NNoverbed NNtable.
a NNnurse NNis NNcaring NNfor NNa NNclient NNwho NNhas NNasthma NNand NNis NNreceiving NNalbuterol. NNfor
NN which NNof NNtheNfollowing NNadverse NNeffects NNshould NNthe NNnurse NNmonitor NNthe NNclient?
A.)
NN Hyperkalemia
B.) NNDyspnea
N
C.) NNTachycardia
D.) NNCandidiasis NN- NNANSWER>>Tachycardia
rationale:
The NNnurse NNshould NNmonitor NNthe NNclient NNfor NNtachycardia, NNwhich NNis NNa NNcommon
NN adverse NNeffectNof NNthis NNmedication, NNespecially NNif NNthe NNclient NNuses NNalbuterol NNon NNa
NN regular NNbasis.
a NNnurse NNis NNpreparing NNa NNclient NNfor NNdischarge NNfollowing NNa NNbronchoscopy NNwith
NN the NNuse NNof NNmoderate NNsedation. NNthe NNnurse NNshould NNidentify NNthat NNwhich NNof NNthe
NN following NNassessments NNifNthe NNpriority?
A.) NNpresence NNof NNgag NNreflex
B.) NNpain NNlevel NNrating NNusing NN0 NNto
NN 10 NNscaleNC.) NNhydration NNstatus
D.) NNappearance NNof NNthe NNIV NNinsertion NNsite NN- NNANSWER>>presence NNof NNgag NNreflex
rationale:
The NNgreatest NNrisk NNto NNthe NNclient NNis NNaspiration NNdue NNto NNa NNdepressed NNgag NNreflex.
NN Therefore, NNtheNpriority NNassessment NNby NNthe NNnurse NNis NNto NNdetermine NNthe NNreturn NNof
NN the NNgag NNreflex.
, a NNnurse NNis NNassessing NNa NNclient NNwho NNhas NNlung NNcancer. NNwhich NNof NNthe NNfollowing
NN manifestationsNshould NNthe NNnurse NNexpect?
A.) NNBlood-tinged NNsputum
B.) NNDecreased NNtactile
NN fremitus NNC.) NNResonance
with NNpercussion
NN
D.) NNPeripheral NNedema NN- NNANSWER>>blood-tinged NNsputum
rationale:
The NNnurse NNshould NNexpect NNblood-tinged NNsputum NNsecondary NNto NNbleeding NNfrom NNthe
NNtumor.
a NNnurse NNworking NNin NNan NNED NNis NNcaring NNfor NNa NNclient NNfollowing NNan NNacute NNchest
NN trauma. NNwhich NNof Nthe NNfollowing NNfindings NNshould NNindicate NNto NNthe NNnurse NNthat NNthe
client NNis NNpossibly NNexperiencingNa NNtension NNpneumothorax?
NN
A.) NNCollapsed NNneck NNveins NNon NNthe NNaffected
NN side NNB.) NNCollapsed NNneck NNveins NNon NNthe
unaffected NNsideNC.) NNTracheal NNdeviation NNto
NN
NN the NNaffected NNside
D.) NNTracheal NNdeviation NNto NNthe NNunaffected NNside NN- NNANSWER>>Tracheal NNdeviation
to NNtheNunaffected NNside
NN
rationale:
The NNnurse NNshould NNrecognize NNthat NNdeviation NNof NNthe NNtrachea NNto NNthe NNunaffected
NN side NNis NNa NNpossible NNindicator NNthat NNthe NNclient NNis NNexperiencing NNa NNtension
NN pneumothorax. NNA NNtension NNpneumothorax NNresults NNfrom NNfree NNair NNfilling NNthe
NN chest NNcavity, NNcausing NNthe NNlung NNto NNcollapseNand NNforcing NNthe NNtrachea NNto
NN deviate NNto NNthe NNunaffected NNside.
a NNnurse NNdeveloping NNa NNplan NNof NNcare NNfor NNa NNclient NNwho NNhas NNactive NNTB. NNwhich NNof
the NNfollowingNisolation NNprecautions NNshould NNthe NNnurse NNinclude NNin NNthe NNplan?
NN
pressure alarm sounds. which of the following situations should the nurse recognize as
a possible cause of the alarm?
A.) Excess secretions
B.) Kinks in the tubing
C.) Artificial airway cuff leak
D.) Biting on the endotracheal tube - ANSWER>>artificial airway cuff leak
rationale:
An artificial airway cuff leak interferes with oxygenation and causes the low-pressure
alarm to sound.
a nurse is providing discharge teaching to a client who has a temporary tracheostomy.
which of the following statements by the client indicates an understanding of the
teaching?
A.) "Ringing in the ears is an adverse effect of this medication."
B.) "Have your skin test repeated in 4 months to show a positive result."
C.) "Expect your urine and other secretions to be orange while taking this medication."
D.) "Remember to take this medication with a sip of water just before your first bite of
each meal." - ANSWER>>"I should remove the old twill ties after the new ties are in
place."
rationale:
,As a safety measure, the nurse should teach the client to wait until the new ties are in
place to remove the old ties. This practice can prevent accidental decannulation.
a nurse is caring for 4 clients. which of the following clients is at greatest risk for a
pulmonary embolism?
A.) A client who is 48 hr postoperative following a total hip arthroplasty
B.) A client who is 8 hr postoperative following an open surgical appendectomy
C.) A client who is 2 hr postoperative following an open reduction external fixation of the
right radius
D.) A client who is 4 hr postoperative following a laparoscopic cholecystectomy -
ANSWER>>A client who is 48 hr postoperative following a total hip arthroplasty
rationale:
The nurse should identify that a client who has undergone a total hip arthroplasty
surgery is at greatest risk for a pulmonary embolus because of decreased mobility of
the affected extremity and an increased amount of blood clots forming in the veins of
the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72
hr following the arthroplasty. The nurse should intervene to reduce the risk by applying
sequential compression devices or antiembolic stockings and by administering
anticoagulant medications.
a nurse is caring for a newly admitted client who has emphysema. the nurse should
place the client in which of the following positions to promote effective breathing?
A.) Lateral position with a pillow at the back and over the chest to support the arm
B.) High-Fowler's position with the arms supported on the overbed table
C.) NNSemi-Fowler's NNposition NNwith NNpillows NNsupporting NNboth NNarms
D.) NNSupine NNposition NNwith NNthe NNhead NNof NNthe NNbed NNelevated NNto NN15° NN-
NN ANSWER>>High-Fowler'sNposition NNwith NNthe NNarms NNsupported NNon NNthe NNoverbed
table
NN
,rationale:
The NNnurse NNshould NNplace NNthe NNclient NNin NNa NNposition NNthat NNallows NNfor NNgreater
NN expansion NNof NNtheNchest, NNsuch NNas NNsitting NNupright NNand NNleaning NNslightly NNforward
NN while NNsupporting NNboth NNarms NNwith NNpillows NNfor NNcomfort NNon NNthe NNoverbed NNtable.
a NNnurse NNis NNcaring NNfor NNa NNclient NNwho NNhas NNasthma NNand NNis NNreceiving NNalbuterol. NNfor
NN which NNof NNtheNfollowing NNadverse NNeffects NNshould NNthe NNnurse NNmonitor NNthe NNclient?
A.)
NN Hyperkalemia
B.) NNDyspnea
N
C.) NNTachycardia
D.) NNCandidiasis NN- NNANSWER>>Tachycardia
rationale:
The NNnurse NNshould NNmonitor NNthe NNclient NNfor NNtachycardia, NNwhich NNis NNa NNcommon
NN adverse NNeffectNof NNthis NNmedication, NNespecially NNif NNthe NNclient NNuses NNalbuterol NNon NNa
NN regular NNbasis.
a NNnurse NNis NNpreparing NNa NNclient NNfor NNdischarge NNfollowing NNa NNbronchoscopy NNwith
NN the NNuse NNof NNmoderate NNsedation. NNthe NNnurse NNshould NNidentify NNthat NNwhich NNof NNthe
NN following NNassessments NNifNthe NNpriority?
A.) NNpresence NNof NNgag NNreflex
B.) NNpain NNlevel NNrating NNusing NN0 NNto
NN 10 NNscaleNC.) NNhydration NNstatus
D.) NNappearance NNof NNthe NNIV NNinsertion NNsite NN- NNANSWER>>presence NNof NNgag NNreflex
rationale:
The NNgreatest NNrisk NNto NNthe NNclient NNis NNaspiration NNdue NNto NNa NNdepressed NNgag NNreflex.
NN Therefore, NNtheNpriority NNassessment NNby NNthe NNnurse NNis NNto NNdetermine NNthe NNreturn NNof
NN the NNgag NNreflex.
, a NNnurse NNis NNassessing NNa NNclient NNwho NNhas NNlung NNcancer. NNwhich NNof NNthe NNfollowing
NN manifestationsNshould NNthe NNnurse NNexpect?
A.) NNBlood-tinged NNsputum
B.) NNDecreased NNtactile
NN fremitus NNC.) NNResonance
with NNpercussion
NN
D.) NNPeripheral NNedema NN- NNANSWER>>blood-tinged NNsputum
rationale:
The NNnurse NNshould NNexpect NNblood-tinged NNsputum NNsecondary NNto NNbleeding NNfrom NNthe
NNtumor.
a NNnurse NNworking NNin NNan NNED NNis NNcaring NNfor NNa NNclient NNfollowing NNan NNacute NNchest
NN trauma. NNwhich NNof Nthe NNfollowing NNfindings NNshould NNindicate NNto NNthe NNnurse NNthat NNthe
client NNis NNpossibly NNexperiencingNa NNtension NNpneumothorax?
NN
A.) NNCollapsed NNneck NNveins NNon NNthe NNaffected
NN side NNB.) NNCollapsed NNneck NNveins NNon NNthe
unaffected NNsideNC.) NNTracheal NNdeviation NNto
NN
NN the NNaffected NNside
D.) NNTracheal NNdeviation NNto NNthe NNunaffected NNside NN- NNANSWER>>Tracheal NNdeviation
to NNtheNunaffected NNside
NN
rationale:
The NNnurse NNshould NNrecognize NNthat NNdeviation NNof NNthe NNtrachea NNto NNthe NNunaffected
NN side NNis NNa NNpossible NNindicator NNthat NNthe NNclient NNis NNexperiencing NNa NNtension
NN pneumothorax. NNA NNtension NNpneumothorax NNresults NNfrom NNfree NNair NNfilling NNthe
NN chest NNcavity, NNcausing NNthe NNlung NNto NNcollapseNand NNforcing NNthe NNtrachea NNto
NN deviate NNto NNthe NNunaffected NNside.
a NNnurse NNdeveloping NNa NNplan NNof NNcare NNfor NNa NNclient NNwho NNhas NNactive NNTB. NNwhich NNof
the NNfollowingNisolation NNprecautions NNshould NNthe NNnurse NNinclude NNin NNthe NNplan?
NN
