NR 324: Exam 1 practice quiz
Questions with verified Answers
A client is experiencing 8/10 incisional pain, resulting in a poor cough effort, and has
course scattered rhonchi after a thoracotomy. Which action should the nurse take first?
a. Medicate the patient with prescribed pain medication.
b. Splint the patient's chest during coughing.
c. Observe the patient use the incentive spirometer.
d. Assess the patient's oxygenation using a pulse oximetry. - ANSWERSa
When we look at the data in this question, the client is having a poor cough effort due to
the pain. If we can take care of the pain, the client should be able to have a better
cough effort, expel mucous, and the rhonchi would clear up. The other options might be
interventions we would also perform, however, they would not resolve the problem.
The nurse is worried that a patient who is not entirely reliable is being discharged home
on therapy for multidrug-resistant tuberculosis. What strategy is the best to use for this
patient?
a. IV drug administration
b. Remain in the hospital
c. Direct observation therapy
d. Isolation - ANSWERSc
Direct observation therapy is the best way to ensure clients are taking their tuberculosis
medications. The most important intervention we can do as nurses caring for clients
with TB, is to ensure medication compliance. In direct observation therapy, a person
drives to the client's house and administers the medication each day.
The emergency department nurse is assessing a patient who has sustained a blunt
injury to the right chest wall. Which findings indicate the presence of a pneumothorax?
(Select all that apply)
a. Decreased chest expansion on the right side
b. The presence of a barrel chest
c. Diminished or absent breath sounds on the affected side
d. Tachypnea
e. Tachycardia - ANSWERSa c d e
Diminished or absent breath sounds on the affected side is correct because the lung is
collapsed, so you will not hear lung sounds over that lung.
Decreased chest expansion on the affected side is correct because again, the lung is
collapsed and will not expand.
Tachycardia and tachypnea will occur due to the lack of gas exchange. The heart will
start pumping faster to try to perfuse the body with whatever oxygenated blood it has,
and the respiratory rate will increase to try to get more oxygen in.
The presence of barrel chest is not associated with a pneumothorax. It is a physiological
change that we see in patients with COPD.
, A nurse is caring for a client with pneumonia who has a new tracheostomy requiring
frequent suctioning. The nurse anticipates what possible clinical problems?
(Select all that apply)
a. Acute pain
b. Hyponatremia
c. Impaired gas exchange
d. Fluid volume deficit
e. Ineffective airway clearance - ANSWERSacde
Impaired gas exchange is correct due to consolidation in the lungs, leaving less
available surface area in the alveoli for gas exchange.
Ineffective airway clearance is correct due to the client having a new trach, requiring
frequent suctioning. This indicates that the client cannot clear their own secretions.
Acute pain is correct, due to having a new trach, and also due to pleuritic chest pain that
can be anticipated in a client with pneumonia.
Fluid volume deficit is correct, due to a presumed lack of intake due to the new trach
combined with infection.
Hyponatremia would not occur in this client. If the client is deficient of fluid, we may see
hypernatremia.
A client has been receiving IV fluids at 150 mL/hr. Which assessments indicate the
client has fluid volume excess?
(Select all that apply)
a. Weak, thready pulses
b. Stridor
c. Distended neck veins
d. S3 heart sound
e. Pitting edema - ANSWERScde
Distended neck veins, or JVD, is correct, and seen in fluid excess due to the increased
fluid in the intravascular space.
Pitting edema is correct. The increased volume causes increased capillary hydrostatic
pressure, which pushes fluid out of the vessel and into the interstitial space, causing
edema.
S3 heart sound is correct. We hear this sound when there is excess fluid in the body.
Stridor is incorrect. The adventitious sound we may hear in clients with fluid excess is
crackles.
Weak, thready pulse is incorrect. Because of the high volume and high pressure within
the vasculature, clients with fluid excess will have bounding pulses.
A nurse is assessing a client with fluid volume excess and a sodium level of 120 mEq/L.
What clinical manifestations would the nurse expect?
(Select all that apply)
a. Dry mucous membranes
b. Headache
c. Tachycardia
d. Confusion
Questions with verified Answers
A client is experiencing 8/10 incisional pain, resulting in a poor cough effort, and has
course scattered rhonchi after a thoracotomy. Which action should the nurse take first?
a. Medicate the patient with prescribed pain medication.
b. Splint the patient's chest during coughing.
c. Observe the patient use the incentive spirometer.
d. Assess the patient's oxygenation using a pulse oximetry. - ANSWERSa
When we look at the data in this question, the client is having a poor cough effort due to
the pain. If we can take care of the pain, the client should be able to have a better
cough effort, expel mucous, and the rhonchi would clear up. The other options might be
interventions we would also perform, however, they would not resolve the problem.
The nurse is worried that a patient who is not entirely reliable is being discharged home
on therapy for multidrug-resistant tuberculosis. What strategy is the best to use for this
patient?
a. IV drug administration
b. Remain in the hospital
c. Direct observation therapy
d. Isolation - ANSWERSc
Direct observation therapy is the best way to ensure clients are taking their tuberculosis
medications. The most important intervention we can do as nurses caring for clients
with TB, is to ensure medication compliance. In direct observation therapy, a person
drives to the client's house and administers the medication each day.
The emergency department nurse is assessing a patient who has sustained a blunt
injury to the right chest wall. Which findings indicate the presence of a pneumothorax?
(Select all that apply)
a. Decreased chest expansion on the right side
b. The presence of a barrel chest
c. Diminished or absent breath sounds on the affected side
d. Tachypnea
e. Tachycardia - ANSWERSa c d e
Diminished or absent breath sounds on the affected side is correct because the lung is
collapsed, so you will not hear lung sounds over that lung.
Decreased chest expansion on the affected side is correct because again, the lung is
collapsed and will not expand.
Tachycardia and tachypnea will occur due to the lack of gas exchange. The heart will
start pumping faster to try to perfuse the body with whatever oxygenated blood it has,
and the respiratory rate will increase to try to get more oxygen in.
The presence of barrel chest is not associated with a pneumothorax. It is a physiological
change that we see in patients with COPD.
, A nurse is caring for a client with pneumonia who has a new tracheostomy requiring
frequent suctioning. The nurse anticipates what possible clinical problems?
(Select all that apply)
a. Acute pain
b. Hyponatremia
c. Impaired gas exchange
d. Fluid volume deficit
e. Ineffective airway clearance - ANSWERSacde
Impaired gas exchange is correct due to consolidation in the lungs, leaving less
available surface area in the alveoli for gas exchange.
Ineffective airway clearance is correct due to the client having a new trach, requiring
frequent suctioning. This indicates that the client cannot clear their own secretions.
Acute pain is correct, due to having a new trach, and also due to pleuritic chest pain that
can be anticipated in a client with pneumonia.
Fluid volume deficit is correct, due to a presumed lack of intake due to the new trach
combined with infection.
Hyponatremia would not occur in this client. If the client is deficient of fluid, we may see
hypernatremia.
A client has been receiving IV fluids at 150 mL/hr. Which assessments indicate the
client has fluid volume excess?
(Select all that apply)
a. Weak, thready pulses
b. Stridor
c. Distended neck veins
d. S3 heart sound
e. Pitting edema - ANSWERScde
Distended neck veins, or JVD, is correct, and seen in fluid excess due to the increased
fluid in the intravascular space.
Pitting edema is correct. The increased volume causes increased capillary hydrostatic
pressure, which pushes fluid out of the vessel and into the interstitial space, causing
edema.
S3 heart sound is correct. We hear this sound when there is excess fluid in the body.
Stridor is incorrect. The adventitious sound we may hear in clients with fluid excess is
crackles.
Weak, thready pulse is incorrect. Because of the high volume and high pressure within
the vasculature, clients with fluid excess will have bounding pulses.
A nurse is assessing a client with fluid volume excess and a sodium level of 120 mEq/L.
What clinical manifestations would the nurse expect?
(Select all that apply)
a. Dry mucous membranes
b. Headache
c. Tachycardia
d. Confusion
