NSG 223 Mod 2 - Practice Exam
Questions Correct Answers
The nurse is caring for a client suspected of having acute respiratory
| | | | | | | | | | | |
distress
syndrome (ARDS). What is the most likely diagnostic test ordered in the
| | | | | | | | | | | |
early stages of
| |
this disease to differentiate the client's symptoms from those of a
| | | | | | | | | | |
cardiac etiology? |
A. Carboxyhemoglobin level
| |
B. Brain natriuretic peptide (BNP) level
| | | | |
C. C-reactive protein (CRP) level
| | | |
D. Complete blood count
| | |
ANS: B Rationale: Common diagnostic tests performed for clients with
| | | | | | | | | |
potential ARDS include plasma brain natriuretic peptide (BNP) levels,
| | | | | | | | |
echocardiography, and pulmonary artery catheterization. The BNP level | | | | | | | |
is helpful in distinguishing ARDS from cardiogenic pulmonary edema.
| | | | | | | | |
The carboxyhemoglobin level will be increased in a client with an
| | | | | | | | | | |
inhalation injury, which commonly progresses into ARDS. CRP and CBC
| | | | | | | | | |
levels do not help differentiate from a cardiac problem.
| | | | | | | |
,The perioperative nurse is writing a care plan for a client who has
| | | | | | | | | | | | |
returned from |
surgery 2 hours ago. Which measure should the nurse implement to
| | | | | | | | | | |
most decrease the| |
client's risk of developing pulmonary emboli (PE)?
| | | | | |
A. Early ambulation
| |
B. Increased dietary intake of protein
| | | | |
C. Maintaining the client in a supine position
| | | | | | |
D. Administering aspirin with warfarin
| | | |
ANS: A Rationale: For clients at risk for PE, the most effective approach
| | | | | | | | | | | | |
for prevention is to prevent deep vein thrombosis. Active leg exercises
| | | | | | | | | | |
to avoid venous stasis, early ambulation, and use of elastic compression
| | | | | | | | | | |
stockings are general preventive measures. The client does not require
| | | | | | | | | |
increased dietary intake of protein directly related to prevention of PE,
| | | | | | | | | | |
although it will assist in wound healing during the postoperative period.
| | | | | | | | | | |
The client should not be maintained in one position, but frequently
| | | | | | | | | | |
repositioned unless contraindicated by the surgical procedure. Aspirin
| | | | | | | |
should never be given with warfarin because it will increase the client's
| | | | | | | | | | | |
risk for bleeding.
| |
A client presents to the emergency department after being in a boating
| | | | | | | | | | | |
accident
about 3 hours ago. Now the client reports headache, fatigue, and the
| | | | | | | | | | | |
feeling of not being | | |
,able to breathe enough. The nurse notes that the client is restless and
| | | | | | | | | | | | |
tachycardic with an | |
elevated blood pressure. This client may be in the early stages of which
| | | | | | | | | | | | |
respiratory
problem?
A. Pneumoconiosis
|
B. Pleural effusion
| |
C. Acute respiratory failure
| | |
D. Pneumonia
|
ANS: C Rationale: Early signs of acute respiratory failure are those
| | | | | | | | | | |
associated with impaired oxygenation and may include restlessness,
| | | | | | | |
fatigue, headache, dyspnea, air hunger, tachycardia, and increased
| | | | | | | |
blood pressure. As the hypoxemia progresses, more obvious signs may
| | | | | | | | | |
be present, including confusion, lethargy, tachycardia, tachypnea,
| | | | | | |
central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia
| | | | | | | |
is infectious and would not result from trauma. Pneumoconiosis results
| | | | | | | | | |
from exposure to occupational toxins. A pleural effusion does not cause
| | | | | | | | | | |
this constellation of symptoms.
| | |
A client is receiving thrombolytic therapy for the treatment of
| | | | | | | | | |
pulmonary emboli. |
What is the best way for the nurse to assess the client's oxygenation
| | | | | | | | | | | | |
status at the | |
, bedside?
A. Obtain serial ABG samples.
| | | |
B. Monitor pulse oximetry readings.
| | | |
C. Perform chest auscultation.
| | |
D. Monitor incentive spirometry volumes.
| | | |
ANS: B Rationale: The nurse assesses the client with pulmonary emboli
| | | | | | | | | | |
frequently for signs of hypoxemia and monitors the pulse oximetry
| | | | | | | | | |
values to evaluate the effectiveness of the oxygen therapy. ABGs are
| | | | | | | | | | |
accurate indicators of oxygenation status, but are not analyzed at the
| | | | | | | | | | |
bedside. PFTs and incentive spirometry volumes do not accurately
| | | | | | | | |
reveal oxygenation status. | |
A client with thoracic trauma is admitted to the ICU. The nurse notes the
| | | | | | | | | | | | |
client's chest
| |
and neck are swollen and there is a crackling sensation when palpated.
| | | | | | | | | | | |
The nurse |
consequently identifies the presence of subcutaneous emphysema. If | | | | | | | |
this condition
|
becomes severe and threatens airway patency, what intervention is
| | | | | | | | |
indicated?
A. A chest tube
| | |
B. A tracheostomy
| |
C. An endotracheal tube
| | |
Questions Correct Answers
The nurse is caring for a client suspected of having acute respiratory
| | | | | | | | | | | |
distress
syndrome (ARDS). What is the most likely diagnostic test ordered in the
| | | | | | | | | | | |
early stages of
| |
this disease to differentiate the client's symptoms from those of a
| | | | | | | | | | |
cardiac etiology? |
A. Carboxyhemoglobin level
| |
B. Brain natriuretic peptide (BNP) level
| | | | |
C. C-reactive protein (CRP) level
| | | |
D. Complete blood count
| | |
ANS: B Rationale: Common diagnostic tests performed for clients with
| | | | | | | | | |
potential ARDS include plasma brain natriuretic peptide (BNP) levels,
| | | | | | | | |
echocardiography, and pulmonary artery catheterization. The BNP level | | | | | | | |
is helpful in distinguishing ARDS from cardiogenic pulmonary edema.
| | | | | | | | |
The carboxyhemoglobin level will be increased in a client with an
| | | | | | | | | | |
inhalation injury, which commonly progresses into ARDS. CRP and CBC
| | | | | | | | | |
levels do not help differentiate from a cardiac problem.
| | | | | | | |
,The perioperative nurse is writing a care plan for a client who has
| | | | | | | | | | | | |
returned from |
surgery 2 hours ago. Which measure should the nurse implement to
| | | | | | | | | | |
most decrease the| |
client's risk of developing pulmonary emboli (PE)?
| | | | | |
A. Early ambulation
| |
B. Increased dietary intake of protein
| | | | |
C. Maintaining the client in a supine position
| | | | | | |
D. Administering aspirin with warfarin
| | | |
ANS: A Rationale: For clients at risk for PE, the most effective approach
| | | | | | | | | | | | |
for prevention is to prevent deep vein thrombosis. Active leg exercises
| | | | | | | | | | |
to avoid venous stasis, early ambulation, and use of elastic compression
| | | | | | | | | | |
stockings are general preventive measures. The client does not require
| | | | | | | | | |
increased dietary intake of protein directly related to prevention of PE,
| | | | | | | | | | |
although it will assist in wound healing during the postoperative period.
| | | | | | | | | | |
The client should not be maintained in one position, but frequently
| | | | | | | | | | |
repositioned unless contraindicated by the surgical procedure. Aspirin
| | | | | | | |
should never be given with warfarin because it will increase the client's
| | | | | | | | | | | |
risk for bleeding.
| |
A client presents to the emergency department after being in a boating
| | | | | | | | | | | |
accident
about 3 hours ago. Now the client reports headache, fatigue, and the
| | | | | | | | | | | |
feeling of not being | | |
,able to breathe enough. The nurse notes that the client is restless and
| | | | | | | | | | | | |
tachycardic with an | |
elevated blood pressure. This client may be in the early stages of which
| | | | | | | | | | | | |
respiratory
problem?
A. Pneumoconiosis
|
B. Pleural effusion
| |
C. Acute respiratory failure
| | |
D. Pneumonia
|
ANS: C Rationale: Early signs of acute respiratory failure are those
| | | | | | | | | | |
associated with impaired oxygenation and may include restlessness,
| | | | | | | |
fatigue, headache, dyspnea, air hunger, tachycardia, and increased
| | | | | | | |
blood pressure. As the hypoxemia progresses, more obvious signs may
| | | | | | | | | |
be present, including confusion, lethargy, tachycardia, tachypnea,
| | | | | | |
central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia
| | | | | | | |
is infectious and would not result from trauma. Pneumoconiosis results
| | | | | | | | | |
from exposure to occupational toxins. A pleural effusion does not cause
| | | | | | | | | | |
this constellation of symptoms.
| | |
A client is receiving thrombolytic therapy for the treatment of
| | | | | | | | | |
pulmonary emboli. |
What is the best way for the nurse to assess the client's oxygenation
| | | | | | | | | | | | |
status at the | |
, bedside?
A. Obtain serial ABG samples.
| | | |
B. Monitor pulse oximetry readings.
| | | |
C. Perform chest auscultation.
| | |
D. Monitor incentive spirometry volumes.
| | | |
ANS: B Rationale: The nurse assesses the client with pulmonary emboli
| | | | | | | | | | |
frequently for signs of hypoxemia and monitors the pulse oximetry
| | | | | | | | | |
values to evaluate the effectiveness of the oxygen therapy. ABGs are
| | | | | | | | | | |
accurate indicators of oxygenation status, but are not analyzed at the
| | | | | | | | | | |
bedside. PFTs and incentive spirometry volumes do not accurately
| | | | | | | | |
reveal oxygenation status. | |
A client with thoracic trauma is admitted to the ICU. The nurse notes the
| | | | | | | | | | | | |
client's chest
| |
and neck are swollen and there is a crackling sensation when palpated.
| | | | | | | | | | | |
The nurse |
consequently identifies the presence of subcutaneous emphysema. If | | | | | | | |
this condition
|
becomes severe and threatens airway patency, what intervention is
| | | | | | | | |
indicated?
A. A chest tube
| | |
B. A tracheostomy
| |
C. An endotracheal tube
| | |
